your 2020 2021 employee benefits guide...your 2020‐2021 employee benefits guide inside our...

YOUR 2020‐2021 EMPLOYEE BENEFITS GUIDE

InsideOur employees are our most valuable asset.

That’s why at Virginia Surgery Associates, PC we are committed to a comprehensive employee benefit program that helps our employees stay healthy, feel secure, and maintain a work/life balance. You may access additional information about your benefits at www.vasurgery/benefits.

Stay HealthyMedical Insurance Dental Insurance Vision Insurance

Feel Secure Life and Accidental Death & Dismemberment Voluntary Long Term Disability 401(k) Retirement Plan Legal Plan

Enjoy Work/Life Balance Travel Assistance Paid‐Time Off and Holidays Employee Perks

Contact Information (2)

Enrollment Eligibility (3)

Medical and Prescription Benefits (4‐7)

Dental & Vision (8‐9)

Flexible Spending Accounts (10)

Life & Disability & Voluntary Benefits (11)

401 (k) Retirement Benefits & EAP (12)

Legal Plan (13)

Paid Time Off & Holidays (14)

BB&T @ Work (15)

Annual Notices (16‐29)

MEDICAL & PRESCRIPTION DRUGSCignaMember Services Phone Number: 1‐800‐244‐6224Online Member Services and Provider Finder: www.mycigna.com

DENTALDelta Dental of VirginiaMember Services Phone Number: 1‐800‐237‐6060Member Services Website: www.deltadentalva.com

VISIONVSPMember Services Phone Number: 1‐800‐877‐7195Member Services Website: www.vsp.com

FLEXIBLE SPENDING ACCOUNTS (FSA)Paychex – Flexible Spending Account AdministratorMember Services Phone Number: 1‐800‐244‐1771Online Member Services: www.benefits.paychex.com

YOUR 2020‐2021 CONTACT INFORMATION

EMPLOYER PAID LIFE/ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCELincoln Financial GroupContact VSA’s Benefit Administrator

VOLUNTARY BENEFITSAmerican Fidelity Insurance CompanyCompany Representative: Briana NealContact Number: 1‐140‐790‐6241

EMPLOYEE ASSISTANCE PROGRAMS (EAP)Member Services: 1‐800‐327‐2255

LEGAL PLANLegal ResourcesContact Number: 1‐800‐728‐5768Online Member Services: www.legalresources.com

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NEW HIRESNew hires who are Class 1 employees and regularly scheduled to work more than 30 or more hours per week are eligible for all benefits on the 1st of the month following date of hire. Class 2 Employees who are regularly scheduled to work more than 30 hours or more per week are eligible for all benefits on the 1st of the month following 45 days from date of hire. All enrollment forms must be turned in to HR no later than 30 days after date of hire.

OPEN ENROLLMENTEach year, we have an annual “Open Enrollment” period for benefit plans. During “Open Enrollment”, you maymake changes to your benefit program (change plans, elect new coverage, add or delete eligible dependents).

All changes take effect on October 1, 2020

QUALIFYING EVENTSEmployees are only able to make changes during Open Enrollment unless you experience a Qualifying Event throughout the plan year. Below are examples of qualifying life events:

• Birth, adoption, placement for foster care, legal custody of a child• Marriage, divorce, legal separation• Gain or loss of spouse’s coverage due to change in employment• Gain or loss of a child’s eligibility• Gain or loss of coverage under Medicare or Medicaid• Death of spouse or child• COBRA coverage expires• Significant change in health care cost of spouse• Gain or loss of coverage during spouse’s annual enrollment • Loss of child(ren) coverage under a parent’s plan due to eligibility requirements

HOW LONG DO I HAVE TO REQUEST ENROLLMENT DUE TO A QUALIFYING EVENT?• You or your dependent must request enrollment within 30 days after losing eligibility for coverage or

after a marriage, birth, adoption, or placement for foster care. • You or your dependent must request enrollment within 60 days of the loss of coverage under a State

CHIP or Medicaid program or the determination of eligibility for premium assistance under those programs.

ELIGIBLE DEPENDENTSYour eligible dependents include:

• Legal spouse/Domestic partners• Your child(ren)

• Children must be natural, legally adopted, or placed with you for legal adoption• Children are covered up to the age of 26

When Can I Enroll?

ENROLLMENT ELIGIBILITY

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MEDICAL & PRESCRIPTION DRUG BENEFITS AT‐A‐GLANCE

Medical Benefits

Cigna Open Access Plus HMO 90%

Who is Eligible and When:

Class 1 Employees are eligible on the 1st of the month following date of hire , and Class 2 Employees are eligible 1st of the month following 45 days from date of hire. Employees must work at least 30 hours per week to be eligible.

The Cigna Open Access Plus HMO plan provides you with medical coverage through the Cigna national network of preferred physicians and other health care practitioners. No referrals are needed and you are not required to select a Primary Care Physician (PCP).

Cigna Open Access Plus HMO 90%

Plan Features In‐Network You Pay Out‐of‐Network You Pay

Annual Deductible $500/$1,000 No Coverage

Coinsurance 90%/10% No Coverage

Out‐of‐Pocket Maximum $4,500 Individual/$9,000 family No Coverage

Primary Care Office Visit $25 per visit No Coverage

Specialist Office Visit $50 per visit No Coverage

Preventive Care No charge No Coverage

Urgent Care Visit $75 Copay No Coverage

Emergency Room $200 Copay (waived if admitted) Paid as In‐network benefit

Inpatient Hospital Services Deductible plus 10% coinsurance No Coverage

Outpatient Hospital Services Deductible plus 10% coinsurance No Coverage

Prescription Drug Coverage – Retail (30 day supply)

Tier 1 = $15

Tier 2 = $45

Tier 3 = $75

Prescription Drug Coverage – Mail Order (90 day supply)

Tier 1 = $45

Tier 2 = $135

Tier 3 = $225

Employee Cost Per Pay Period

Employee Employee & Child(ren) Employee & Spouse Family

$84.76 $351.32 $388.39 $709.99

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Medical Benefits

Cigna Open Access Plus PPO 100/70


Class 1 Employees are eligible on the 1st of the month following date of hire, and Class 2 Employees are eligible 1st of the month following 45 days from date of hire. Employees must work at least 30 hours per week to be eligible.

The Cigna Open Access Plus PPO 100/70 Plan provides you with medical coverage through the Cigna national network of physicians and other health care practitioners. You may also access services from non‐preferred physicians and other health care practitioners; however, your Out‐Of‐Pocket cost may be higher if you do so. The below chart gives a side‐by‐side look at the amounts you pay when you use in‐network and out‐of‐network providers.



$105.35 $443.97 $487.55 $853.97

Cigna Open Access Plus PPO 100/70


Annual Deductible $500/$1,000 $1,000 Individual/$2,000 Family

Coinsurance 100% 70%/30%

Out‐of‐Pocket Maximum $4,500 Individual/$9,000 Family $9,000 Individual/$18,000 Family

Primary Care Office Visit $20 Copay 30% after Deductible

Specialist Office Visit $40 Copay 30% after Deductible

Preventive Care No Charge 30% after Deductible

Urgent Care Visit $75 Copay 30% after Deductible

Emergency Room $200 Copay (waived if admitted)

Inpatient Hospital Services Deductible plus $500 Copay per admission

30% after Deductible

Outpatient Hospital Services Deductible plus $300 Copay 30% after Deductible


Tier 1 = $15

Tier 2 = $45

Tier 3 = $75


Tier 1 = $45

Tier 2 = $135

Tier 3 = $225

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Medical Benefits

Cigna Open Access Plus PPO HSA 1500



The Cigna Open Access Plus PPO HSA 1500 Compatible Plan provides you with medical coverage through the Cigna national network of physicians and other health care practitioners. You may also access services from non‐preferred physicians and other health care practitioners; however, your Out‐Of‐Pocket cost may be higher if you do so. The below chart gives a side‐by‐side look at the amounts you pay when you use in‐network and out‐of‐network providers.



$24.45 $287.30 $317.61 $613.39

Cigna Open Access Plus PPO HSA 1500


Annual Deductible $1,500 Individual/$3,000 Family $3,000 Individual/$6,000 Family

Coinsurance 100% 70%/30%

Out‐of‐Pocket Maximum $3,000 Individual/$6,000 Family $6,000 Individual/$12,000 Family

Primary Care Office Visit $20 Copay after Deductible 30% after Deductible

Specialist Office Visit $40 Copay after Deductible 30% after Deductible

Preventive Care No Charge 30% after Deductible

Urgent Care Services $75 Copay after Deductible 30% after Deductible

Emergency Room $200 Copay after Deductible (waived if admitted)

Inpatient Hospital Services No charge after Deductible 30% after Deductible

Outpatient Hospital Services No charge after Deductible 30% after Deductible


Integrated deductible with medicalTier 1 = $15Tier 2 = $45Tier 3 = $75


Integrated deductible with medicalTier 1 = $45Tier 2 = $130Tier 3 = $225

Employer will fund $250.00 annually spread evenly per pay period to any employee participating in the HSA plan while employed at VSA. 6

WHAT IS A HEALTH SAVINGS ACCOUNT

A health savings account is a tax‐advantaged medical savings account available to taxpayers who are enrolled in a high deductible health plan (HDHP).

• In order to open a Health Savings Account you must be enrolled in the high deductible health plan. (The CignaOpen Access Plus PPO HSA 1500 is a HDHP.)

• The funds contributed to an HSA are not subject to federal income tax at the time of deposit.

• The maximum contribution to your HSA account for 2020 is $3,550 for individuals and $7,100 for families. The2021 maximum contribution is $3,600 for individuals and $7,200 for families. If over the age of 55, there is anadditional catch‐up contribution allowed of $1,000.

• An HSA is 100% employee owned and the funds in the account are carried over each year.

• Health Savings Accounts are not tied to an employer and stay with you even if you change jobs.

• HSA funds can be used to pay for qualified medical expenses at any time without federal tax liability or penalty.Withdrawals for non‐medical expenses are subject to a 20% penalty and corresponding tax liabilities.

• At any point if you are no longer enrolled in a high deductible health plan, you can continue to use the fundsfor qualified medical expenses, but you can no longer contribute funds to your HSA account.

Potential Tax Savings of an HSABecause HSA after‐tax contributions can be deducted from your federal income tax return, you can realize tax savings each year you contribute. Below is an example of how your HSA can save you a significant amount of money each year.

With an HSA Without an HSA

Annual Income $50,000 $50,000

HSA Annual Individual Contribution $3,350 $0

Taxable Income $46,650 $50,000

Estimated Taxes (28%) $13,062 $14,000

Tax Savings $854 $0

(This hypothetical example is for illustrative purposes only and is not intended to represent any specific benefits plan or potential plan savings.)

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DENTAL BENEFITS AT‐A‐GLANCE

Dental Benefits

Delta Dental


Class 1 Employees are eligible on the 1st of the month following date of hire and Class 2 Employees are eligible 1st of the month following 45 days from date of hire. Employees must work at least 30 hours per week to be eligible.

Delta Dental of Virginia PPO Dental plan provides a comprehensive coverage with a nationwide PPO network. This gives members access to more in‐network dentists, making it easier for them to reduce out‐of‐pocket costs for covered procedures and treatments.

The dental frequencies:• Preventative care covers two oral exams and two cleanings each year • Fluoride treatment (to age 19; 1 per year)• Full mouth/panelipse x‐rays (one time every 3 years)• Bitewing X‐rays (one time every 12 months, limited to 4 bitewings)• Sealants (under age 16, one application per tooth)

Dental Plan Features PPO Premier Out‐of‐Network

Type A: Preventive Services 100% 90% 90%

Type B: Basic Services

(Endodontics & Periodontics)80% 70% 70%

Type C: Major Services 50% 50% 50%

Type D: Orthodontia – Adult and Child 50% 50% 50%

Orthodontia Lifetime $2,500 $2,500 $2,500

Contract Year Deductible:

Applies to Type B and C services only

$50 Single

$150 Family

$50 Single

$150 Family

$50 Single

$150 Family

Annual Benefit Maximum: Per Person$5,000 $5,000 $5,000


Employee Employee &

Child

Employee & Children

Employee & Spouse

Family

$13.72 $35.90 $35.90 $34.59 $64.59

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VISION BENEFITS AT‐A‐GLANCE

VSP Vision Plan


Class 1 Employees are eligible on the 1st of the month following date of hire and Class 2 Employees are eligible 1st of the month following 45 days from date of hire. Employees must work at least 30 hours per week to be eligible.

Professional vision services including routine eye examinations, eyeglasses and contact lenses are offered through VSP Vision Services. VSP is the largest private provider vision carrier in the country. When you visit a VSP participating provider, your benefits include routine vision exams, lenses and preferred pricing on all patient options. The Choice Plan is a premier full service plan with choice, flexibility and maximum value through VSP Preferred Providers.

Frequency: Eye Exam 12 months/ Lenses 12 months/ Frames 24 months/ Contact Lenses 12 months

Visit www.vsp.com or call VSP Vision at 800‐877‐7195 to locate participating providers.

VSP Choice Plan Features In Network You Pay Out of Network You Pay

Eye Examination

Every 12 Months

$10 Copay Plan pays up to $45, you pay balance

Lenses:

Single Vision, Bifocal, Trifocal

Every 12 Months

Frames:

Every 24 Months

$25 Copay (Anti‐reflective coating is included)

$130 allowance for a wide selection of frames

Single Vision Plan pays up to $30, you pay the balance

Lined Bifocal Plan pays up to $50, you pay balance

Lined Trifocal Plan pays up to $65, you pay balance

Plan pays up to $70, you pay balance

Contact Lenses

Every 12 Months

$130 allowance for contacts, copay does not apply

Plan pays up to $105, you pay balance



$4.14 $7.13 $6.98 $11.49

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FSA BENEFITS AT‐A‐GLANCE

Flexible Spending Accounts (FSA)


Employees are eligible on the date of hire. Employees must work at least 30 hours per week to be eligible.

FSAs provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pretax basis. By anticipating your family’s health care and dependent care costs for the next year, you can actually lower your taxable income. If you are enrolled in the HSA you must have a “limited purpose” FSA with HSA election‐dental, vision, dependent care.

Health Care Reimbursement FSA

This program lets VSA’s employees pay for certain IRS‐approved medical care expenses with a prescription (as of January 1, 2010 under health care reform) not covered by their insurance plan with pretax dollars. The annual maximum amount you may contribute to the Health Care Reimbursement FSA is $2,750. Some examples include:

Hearing services, including hearing aids and batteries

Vision services, including contact lenses, contact lens solution, eye examinations and

eyeglasses

Dental services and orthodontia

Chiropractic services

Acupuncture

Prescription contraceptives

Dependent Care FSA

The Dependent Care FSA lets VSA’s employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or caring for elders. The annual maximum amount you may contribute to the Dependent Care FSA is $5,000 (or $2,500 if married and filing separately) per calendar year. Examples include:

The cost of child or adult dependent care

The cost for an individual to provide care either in or out of your house

Nursery schools and preschools (excluding kindergarten)

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LIFE & AD&D INSURANCE

Life, AD&D & Voluntary Insurance

Life & AD&D



VSA provides employees with a life insurance/Accidental Death & Dismemberment benefit of $30,000. Death benefits are paid to the designated beneficiary. Benefits are also paid for accidental death, dismemberment, and loss of sight. VSA pays the full cost of this coverage .

Voluntary Benefits



VSA offers an array of voluntary benefits through American Fidelity Insurance Company, and its business partners. Available coverage’s include:

• Long‐Term Disability• Short‐Term Disability• Term Life• Whole Life• Permanent Life• Accident Plan• Cancer Solutions• Critical Illness

For additional information, please contact the Benefits Administrator, Melanie Rothrock.

VOLUNTARY BENEFITS

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401(k) RETIREMENT PLAN

401(k) & EAP

VSA offers a 401k Plan through Paychex, allowing employees to plan for their future. Employees are eligible to participate in the plan at their one year anniversary date provided they are 21 years of age and have worked at least 1,000 hours. VSA Owners will match an employee’s contribution per the following schedule.

Employee Contribution Employer Match

One Percent One Percent

Two Percent Two Percent

Three Percent Three Percent

Four Percent Three and One-Half Percent

Five Percent Four Percent

The Plan offers VSA employees the opportunity to select from a comprehensive list of funds to invest and investment advice through Ironview Capital Management. The employee has easy access to manage their contributions, investments, loans and demographic changes through Paychex at https://benefit.paychex.com.

The integrated Employee Assistance Program (EAP), Work/Life, and Wellness benefit is offered to all employees and immediate family members of Virginia Surgery Associates, P.C. through Paychex Balance Works. It is a prepaid and confidential service that provides quick online or telephonic support to assist you with day‐to‐day issues, improve your work/life balance and enhance your well being.

You can contact BalanceWorks toll free at (800) 327‐2255, or you can visit their website at www.eniweb.com. Under “Company Login” enter company ID number PAS220.

EMPLOYEE ASSISTANCE PROGRAM (EAP)

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Legal Plan

Legal Resources

Legal Resources has a network of over 12,000 attorneys throughout the US that will provide you and your familywith legal advice, consultation and representation when needed.

Most legal services are covered in full; 100% of your attorney fees are covered. Any service not fully covered isalways covered at a 25% discount.

For a low monthly rate of $19.00, you, your spouse and qualified dependents can have a law firm on retainer when alegal need arises. You will be obligated to stay on the plan for 12 months if you elect to enroll. If by chance youterminated your employment with VSA during the 12 months, then Legal Resources will reach out to bill you directly.

Any service not covered in full is covered at a 25% discount after free advice and consultation in your attorney’soffice or over the phone.

There are no claim forms to fill out, co‐pays or limits on usage.

Pre‐existing situations are covered at a 25% discount. Services are provided if you become a victim of identity theft.

You may retain this benefit when you leave your employer, at a low group rate.

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PAID HOLIDAYS

VSA understands the need for a true work /life balance. Through our paid Holidayprogram, we encourage you to take time foryourself to re‐energize, spend time with familyand friends, and celebrate these paid holidaysthroughout the year. All full‐time employeesare eligible. In additional to the aboveholidays, you receive one day that must betaken in the same calendar month as yourbirthday with management approval. This dayis considered a floating holiday and is notcarried over as PTO.

VSA Paid Holidays

New Year’s Day

Memorial Day

Independence Day

Labor Day

Thanksgiving & Day After

Christmas Day

Others as designated

PAID TIME OFF

Paid Time Off & Holidays

Employees are eligible for paid time off (PTO). This time can be used for vacation, sick or personal days as well as other time off designated by the practice. All eligible employees will begin accruing PTO upon hire, however successful completion of the introductory period is required prior to use of the leave. Full‐time and part‐time regular employees accrue on a pro‐rated basis based on regular hours worked.

VSA Paid‐Time Off (PTO) Accrual Schedule for non‐exempt full‐time Staff:

Years of Service Total Days Earned (hrs) Hours Accrued each Paycheck

0‐1 10 (80) 3.08

1‐2 12.5 (100) 3.85

2‐3 15 (120) 4.62

3‐4 17.5 (140) 5.38

4‐5 20 (160) 6.15

Max 20 (160) 6.15

All leave is subject to your manager’s final approval.

No more than two (2) consecutive weeks can be taken at one time unless related to illness (with doctors note) or by special approval from the Executive Director.

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BB&T @ Work

BB&T @ Work

BB&T@Work can help you set financial wellness in motion, offering you the resources you need to succeed in your financial life. As an employee of VSA, you are granted access to a comprehensive package of financial tools and services:

• U by BB&T. Online and mobile banking platform goes beyond standard online banking with helpful tools like online budgeting, goal setting, categorized springing history and more. Visit BBT.com/U for more information.

• BB&T Deals. BB&T clients can earn money with BB&T Deals, a program that provides you cash back offers based on your purchase history. The more you shop with your BB&T cards, the more cash you will earn

• Elite@Work Checking. Enjoy a premium package for services and discounts with exclusive account for BB&T@Work employees:

• Monthly maintenance fee waived with combined ACH direct deposits totaling $750 or more per statement cycle

• Free first order of personalized checks• Unlimited transactions at BB&T and non‐BB&T ATMS (fees may be charged by ATM owner)• Bonus interest rates of select CDs and IRSs• A no‐cost 3”X5” or smaller safe deposit box (or a $40 annual discount on larger sizes)• No‐fee money orders and official checks• Two free automatic transfers each statement cycle from overdraft protection• And more!

• Face‐to‐face consultation – Receive a financial review and consultant from a BB&T personal banker, covering everything from everyday banking to loans, investments and more

• Financial education – through BB&T Financial Foundations, you can access more than 20 online training modules to set you on the path to financial wellness. These engaging lessons cover investing, mortgages, retirement and more.

To enroll, visit your local BB&T financial center or go online to BBT.com/atwork.

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Opportunity to enroll or re‐enroll dependents under the age of 26If you have a dependent whose coverage ended, or who was denied coverage (or was not eligible for coverage), because coverage for dependent children under the plan previously ended before they were age 26, they are eligible to enroll or reenroll in our medical plan. You may request enrollment for such children who are under age 26 for 30 days from the date this notice is received. Enrollment will be effective as of the first day of our first plan year beginning on or after September 23, 2010, even if that results in retroactive enrollment. For more information contact Human Resources or call the medical carrier at the telephone number on your insurance identification card.

Lifetime limit not applicable and enrollment opportunityThe lifetime limit on the dollar value of benefits under our medical plan no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment. For more information contact Human Resources or call the medical insurance carrier at the telephone number on your identification card.

Notice on Patient ProtectionsThe medical HMO plan generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. Until you make this designation, the medical carrier designates one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the medical insurance carrier at the number listed on your identification card.

For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the medical insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre‐approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the medical insurance carrier at the number listed on your identification card.

OTC Drug Reimbursements for FSAs/HRAs/HSAsUnder the new Health Care Reform law (PPACA), the cost of an over‐the‐counter medicine or drug cannot be reimbursed from the account unless a prescription is obtained. The change does not affect insulin, even if purchased without a prescription, or other health care expenses such as medical devices, eyeglasses, contact lenses, co‐pays and deductibles. The new standard applies only to purchases made on or after January 1, 2011.

A similar rule is in effect for Health Reimbursement Arrangements (HRAs) and Health Savings Accounts (HSAs).

The IRS has also posted a questions and answers section on its website http://www.irs.gov/newsroom/article/0,,id=227308,00.html concerning these provisions.

Patient Protection and Affordable Care Act

(PPACA) Mandatory Notices

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Notice of Privacy PracticesTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Pledge to You

This notice is intended to inform you of the privacy practices followed by the Virginia Surgery’s Employee Benefit Plan (the Plan) and the Plan’s legal obligations regarding your protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The notice also explains the privacy rights you and your family members have as participants of the Plan. It is effective on April 14, 2011.

The Plan often needs access to your protected health information in order to provide payment for health services and perform plan administrative functions. We want to assure the plan participants covered under the Plan that we comply with federal privacy laws and respect your right to privacy. VSA requires all members of our workforce and third parties that are provided access to protected health information to comply with the privacy practices outlined in this notice.

Protected Health InformationYour protected health information is protected by the HIPAA Privacy Rule. Generally, protected health information is information that identifies an individual created or received by a health care provider, health plan or an employer on behalf of a group health plan that relates to physical or mental health conditions, provision of health care, or payment for health care, whether past, present or future.

How We May Use Your Protected Health InformationUnder the HIPAA Privacy Rule, we may use or disclose your protected health information for certain purposes without your permission. This section describes the ways we can use and disclose your protected health information.

• Payment.We use or disclose your protected health information without your written authorization in order to determine eligibility for benefits, seek reimbursement from a third party, or coordinate benefits with another health plan under which you are covered. For example, a health care provider that provided treatment to you will provide us with your health information. We use that information in order to determine whether those services are eligible for payment under our group health plan.

• Health Care Operations.We use and disclose your protected health information in order to perform plan administration functions such as quality assurance activities, resolution of internal grievances, and evaluating plan performance. For example, we review claims experience in order to understand participant utilization and to make plan design changes that are intended to control health care costs.

• Treatment. Although the law allows use and disclosure of your protected health information for purposes of treatment, as a health plan we generally do not need to disclose your information for treatment purposes. Your physician or health care provider is required to provide you with an explanation of how they use and share your health information for purposes of treatment, payment, and health care operations.

• As permitted or required by law.We may also use or disclose your protected health information without your written authorization for other reasons as permitted by law. We are permitted by law to share information, subject to certain requirements, in order to communicate information on health‐related benefits or services that may be of interest to you, respond to a court order, or provide information to further public health activities (e.g., preventing the spread of disease) without your written authorization. We are also permitted to share protected health information during a corporate restructuring such as a merger, sale, or acquisition. We will also disclose health information about you when required by law, for example, in order to prevent serious harm to you or others.

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Notice of Privacy Practices

• Pursuant to your Authorization.When required by law, we will ask for your written authorization before using or disclosing your protected health information. If you choose to sign an authorization to disclose information, you can later revoke that authorization to prevent any future uses or disclosures.

• To Business Associates. We may enter into contracts with entities known as Business Associates that provide services to or perform functions on behalf of the Plan. We may disclose protected health information to Business Associates once they have agreed in writing to safeguard the protected health information. For example, we may disclose your protected health information to a Business Associate to administer claims. Business Associates are also required by law to protect protected health information.

• To the Plan Sponsor.We may disclose protected health information to certain employees of Virginia Surgery for the purpose of administering the Plan. These employees will use or disclose the protected health information only as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized additional disclosures. Your protected health information cannot be used for employment purposes without your specific authorization.

Your Rights• Right to Inspect and Copy. In most cases, you have the right to inspect and copy the protected health information

we maintain about you. If you request copies, we will charge you a reasonable fee to cover the costs of copying, mailing, or other expenses associated with your request. Your request to inspect or review your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to inspect and copy your health information. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format.

• Right to Amend. If you believe that information within your records is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information. Your request to amend your health information must be submitted in writing to the person listed below. In some circumstances, we may deny your request to amend your health information. If we deny your request, you may file a statement of disagreement with us for inclusion in any future disclosures of the disputed information.

• Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures of your protected health information. The accounting will not include disclosures that were made (1) for purposes of treatment, payment or health care operations; (2) to you; (3) pursuant to your authorization; (4) to your friends or family in your presence or because of an emergency; (5) for national security purposes; or (6) incidental to otherwise permissible disclosures.

Your request to for an accounting must be submitted in writing to the person listed below. You may request an accounting of disclosures made within the last six years. You may request one accounting free of charge within a 12‐month period.

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Notice of Privacy Practices• Right to Request Restrictions. You have the right to request that we not use or disclose information for

treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. You also have the right to request that we limit the protected health information that we disclose to someone involved in your care or the payment for your care, such as a family member or friend.

Your request for restrictions must be submitted in writing to the person listed below. We will consider your request, but in most cases are not legally obligated to agree to those restrictions. However, we will comply with any restriction request if the disclosure is to a health plan for purposes of payment or health care operations (not for treatment) and the protected health information pertains solely to a health care item or service that has been paid for out‐of‐pocket and in full.

• Right to Request Confidential Communications. You have the right to receive confidential communications containing your health information. Your request for restrictions must be submitted in writing to the person listed below. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address.

• Right to be Notified of a Breach. You have the right to be notified in the event that we (or one of our Business Associates) discover a breach of your unsecured protected health information. Notice of any such breach will be made in accordance with federal requirements.

• Right to Receive a Paper Copy of this Notice. If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the person listed below.

Our Legal ResponsibilitiesWe are required by law to protect the privacy of your protected health information, provide you with certain rights with respect to your protected health information, provide you with this notice about our privacy practices, and follow the information practices that are described in this notice.

We may change our policies at any time. In the event that we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below. If you have any questions or complaints, please contact:

Melanie Rothrock703‐429‐2125

ComplaintsIf you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed above. You also may send a written complaint to the U.S. Department of Health and Human Services —Office of Civil Rights. The person listed above can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.

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Other Mandatory Notices

Women’s Health and Cancer Rights Act of 1998

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. If you would like more information on WHCRA benefits, call your plan administrator.

CHIP‐Children's Health Insurance Program (CHIP) Reauthorization Act of 2009

Medicaid and the Children’s Health Insurance Program (CHIP) offer free or low‐cost health coverage to children and families. If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer‐sponsored health coverage, but need assistance in paying their health premiums.

If you or your dependents are already enrolled in Medicaid or CHIP, you can contact your state Medicaid or CHIP office to find out if premium assistance is available. For a list of the contacts in each State, go to www.dol.gov/ebsa/chipmodelnotice.doc.

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, you can 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, you can then contact the State to find out if it has a program that might help you pay the premiums for an employer‐sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.

HIPAA Special Enrollment Rights Notice

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides employees additional opportunities to enroll in a group health plan if they experience a loss of other coverage or certain life events.

If you are declining coverage at this time for either yourself or your eligible dependents, you may be able to enroll yourself and/or your eligible dependents in coverage at a later date if there is a loss of other coverage. You must enroll and provide the required supporting documentation within 31 days of the date your other coverage ends.

In addition, you have a qualifying life event (e.g. change in your marital status, birth or adoption of a child, death of dependent or change in employment status). You must enroll and provide the applicable required supporting documentation within 31 days of the qualifying life event.

For additional information regarding your rights under HIPAA, please visit the US Department of Labor website at the link below: http://www.dol.gove/ebsa/faqs/faq_consumer_hipaa.hmtl

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Premium Assistance Under Medicaid and theChildren’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, 2020. Contact your State for more information on eligibility –

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

Health Plan Plus (CHP+)Website: http://myalhipp.com/Phone: 1-855-692-5447

Health First Colorado Website: https://www.healthfirstcolorado.com/Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plusCHP+ Customer Service: 1-800-359-1991/ State Relay 711

ALASKA – Medicaid FLORIDA – MedicaidThe AK Health Insurance Premium Payment ProgramWebsite: http://myakhipp.com/Phone: 1-866-251-4861Email: [email protected] Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

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

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

Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hippPhone: 678-564-1162 ext 2131

CALIFORNIA – Medicaid INDIANA – MedicaidWebsite: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspxPhone: 1-800-541-5555

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

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IOWA – Medicaid and CHIP (Hawki) MONTANA – MedicaidMedicaid Website: https://dhs.iowa.gov/ime/membersMedicaid Phone: 1-800-338-8366Hawki Website: http://dhs.iowa.gov/HawkiHawki Phone: 1-800-257-8563

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPPPhone: 1-800-694-3084

KANSAS – Medicaid NEBRASKA – Medicaid Website: http://www.kdheks.gov/hcf/default.htmPhone: 1-800-792-4884

Website: http://www.ACCESSNebraska.ne.govPhone: 1-855-632-7633Lincoln: 402-473-7000Omaha: 402-595-1178

KENTUCKY – Medicaid NEVADA – MedicaidKentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website:https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspxPhone: 1-855-459-6328Email: [email protected]

KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspxPhone: 1-877-524-4718

Kentucky Medicaid Website: https://chfs.ky.gov

Medicaid Website: http://dhcfp.nv.govMedicaid Phone: 1-800-992-0900

LOUISIANA – Medicaid NEW HAMPSHIRE – MedicaidWebsite: www.medicaid.la.gov or www.ldh.la.gov/lahippPhone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

Website: https://www.dhhs.nh.gov/oii/hipp.htmPhone: 603-271-5218Toll free number for the HIPP program: 1-800-852-3345, ext 5218

MAINE – Medicaid NEW JERSEY – Medicaid and CHIPWebsite: http://www.maine.gov/dhhs/ofi/public-assistance/index.htmlPhone: 1-800-442-6003TTY: Maine relay 711

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

MASSACHUSETTS – Medicaid and CHIP NEW YORK – MedicaidWebsite: http://www.mass.gov/eohhs/gov/departments/masshealth/Phone: 1-800-862-4840

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

MINNESOTA – Medicaid NORTH CAROLINA – MedicaidWebsite: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical-assistance.jsp [Under ELIGIBILITY tab, see “what if I have other health insurance?”]Phone: 1-800-657-3739

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

MISSOURI – Medicaid NORTH DAKOTA – MedicaidWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htmPhone: 573-751-2005

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

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To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human ServicesEmployee Benefits Security Administration Centers for Medicare & Medicaid Serviceswww.dol.gov/agencies/ebsa www.cms.hhs.gov1‐866‐444‐EBSA (3272) 1‐877‐267‐2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act StatementAccording to the Paperwork Reduction Act of 1995 (Pub. L. 104‐13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection ofinformation if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N‐5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210‐0137. OMB Control Number 1210‐0137 (expires 12/31/2019)

OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1-888-365-3742

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

OREGON – Medicaid VERMONT– Medicaid

Website: http://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.htmlPhone: 1-800-699-9075

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

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP

Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspxPhone: 1-800-692-7462

Website: https://www.coverva.org/hipp/Medicaid Phone: 1-800-432-5924CHIP Phone: 1-855-242-8282

RHODE ISLAND – Medicaid and CHIP WASHINGTON – Medicaid

Website: http://www.eohhs.ri.gov/Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

Website: https://www.hca.wa.gov/Phone: 1-800-562-3022

SOUTH CAROLINA – Medicaid WEST VIRGINIA – MedicaidWebsite: https://www.scdhhs.govPhone: 1-888-549-0820

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

SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIPWebsite: http://dss.sd.govPhone: 1-888-828-0059

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

TEXAS – Medicaid WYOMING – Medicaid

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

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

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OMB 0938‐0990

CMS Form 10182-CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless itdisplays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If youhave comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Important Notice from Virginia Surgery Associates, P.C. About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Virginia Surgery Associates, P.C. and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Virginia Surgery Associates, P.C. has determined that the prescription drug coverage offered by Cigna is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

_________________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

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OMB 0938‐0990



25

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Cigna coverage will not be affected. Plan Name First Tier Second Tier Third Tier Mail OrderOpen Access Plus HMO 90%

$15 copay $45 copay $75 copay

$45/$135/$225

Open Access Plus PPO 100/70

$15 copay $45 copay $75 copay

$45/$135/$225

Open Access Plus PPO HSA 1500

$15 copay after integrated deductible



$45/$135/$225 after integrated deductible

See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with CareFirst and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Virginia Surgery Associates, P.C. changes. You also may request a copy of this notice at any time.

OMB 0938‐0990



26

For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of

your copy of the “Medicare & You” handbook for their telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: July 7, 2020

Name of Entity/Sender: Virginia Surgery Associates, P.C. Contact: Melanie Rothrock

Address: 13135 Lee Jackson Memorial Hwy Suite 305 Fairfax, VA 22033 Phone Number: (703) 429-2125

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).

NOTES

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NOTES

31

This Guide is only intended to offer an outline of benefits. All details and contract obligations of plans are stated in the group contract/insurance documents, including any disclosures (whether regarding “grandfathering” of plans or others) required by the new health reform law, the Patient Protection and Affordable Care Act (PPACA). In the event of conflict between this guide and the group contract/insurance documents, the group contract/insurance documents will prevail. Please contact your Human Resources Department for further information.

@ 2018 McGriff Insurance Services, Inc.

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