Group Health Plan

1. Group Health Plan 2015 Required Legal Notices and Disclosures

2. List of Notices and Disclosures If you want additional information on any of these notices or the benefits they address, contact the City of Casper Human Resources Department, 200 N. David, Casper WY 82601, 307-235-8344. 2014 Required Legal Notices and Disclosures Page 2

3. Notice of Privacy Practices

7. Your Choices Women’s Health and Cancer Rights Act Notice • 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, co-payments and coinsurance applicable to other medical and surgical benefits provided under this plan. See the Summary Plan Description. • Following the initial reconstruction, any additional modification or revision is covered only to the extent that it is not otherwise limited or excluded from coverage by your plan. • For additional information on WHCRA benefits, contact the Human Resource Department at 307-235-8344. 2014 Required Legal Notices and Disclosures Page 7

8. Your Choices Newborns’ and Mothers’ Health Protection Act Under Federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not 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 delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g. your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under Federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under Federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). For plan participants residing in California, the following maternity minimum stay provisions also apply:If the hospital stay is less than 48 hours after a normal vaginal delivery or less than 96 hours after a cesarean delivery, this plan will cover a follow-up visit for the mother and newborn within 48 hours of discharge, when prescribed by the treating physician. This visit shall be provided by a licensed health care provider whose scope of practice includes postpartum and newborn care. The treating physician, in consultation with the mother, shall determine whether this visit shall occur at home, in a medical facility, or at the physician’s office. Mandatory Insurer Reporting Law Employees are required to provide Social Security numbers for all dependents enrolled in the medical plan. You will be asked to enter Social Security numbers for all dependents you enroll on your medical plan. The reason for this requirement is the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMESA). This law requires that providers of group health plans must report certain information (Social Security numbers of plan participants) to the Secretary of Health and Human Services (HHS) to determine Medicare entitlement. The reporting party will be the insurer or third-party administrator,or plan administrator or fiduciary if the plan is self-insured and self-administered. The law also provides penalties for noncompliance. This law became effective on January 1, 2009. 2014 Required Legal Notices and Disclosures Page 8

9. Your Choices Medicare Part D Notice of Creditable Coverage Important Notice from City of Casper AboutYour Prescription Drug Coverage and Medicare If you or your dependents are not eligible for Medicare, you may disregard this notice. This notice applies to those covered under the City of Casper Benefit Plan. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with our Benefit Plan 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 andMedicare’s prescription drug coverage: 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. The sponsor has determined that the prescription drug coverage offered by the City of Casper Plan 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 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current City of Casper Medical coverage will not be affected. Medicare eligible individuals who become eligible for Medicare Part D can keep this coverage if they elect Part D and this plan will pay primary to Medicare Part D coverage. If you do decide to join a Medicare drug plan and drop your current coverage under our plan, be aware that you and your dependents will not be able to get back this coverage back except at the next annual open enrollment or if you have a “special enrollment” event. 2014 Required Legal Notices and Disclosures Page 9

10. Your Choices Medicare Part D Notice of Creditable Coverage • You should also know that if you drop or lose your current coverage with the City of Casper 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 at the number 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 the City of Casper Plan changes. You also may request a copy of this notice at any time. • For More Information About Your Options Under Medicare Prescription Drug Coverage… • More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. • For more information about Medicare prescription drug coverage: • Visit www.medicare.gov. • Call your State Health Insurance Assistance Program (see 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). • 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). • Date: August 25, 2014 • Name of Entity/Sender: City of Casper • Contact--Position/Office: Human Resource Department • Address: 200 N. David, Casper WY 82601 • Phone Number: 307-235-8344 2014 Required Legal Notices and Disclosures Page 10

11. Your Choices HIPAA Special Enrollment Notice You should read this notice even if you plan to waive coverage at this time. This notice explains your right to apply for group health insurance coverage mid-year even if you decline to enroll when you are first eligible (perhaps because you have other coverage), if you gain new dependents mid-year, or if you become eligible for – or lose eligibility for – Medicaid or CHIP coverage mid-year. Loss of Other Coverage 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), except as specified below for Medicaid or CHIP coverage. Marriage, Birth or Adoption 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. Medicaid or CHIP Coverage If you or your dependents become eligible to participate in a Medicaid or Children’s Health Insurance Plan (CHIP) premium assistance program, you may enroll for coverage under our health plan if you notify the plan administrator within 60 days after you become eligible to participate in Medicaid or CHIP. If you or your dependents lose coverage under a Medicaid or CHIP premium assistance program due to loss of eligibility, you may enroll in our health plan if you apply to enroll within sixty (60) days of the loss of coverage under Medicaid or CHIP. If you enroll within sixty (60) days, the effective date of coverage is the first day after your Medicaid or CHIP coverage ended. To request special enrollment or obtain more information, contact the City of Casper Human Resource Department, 200 N. David, Casper WY 82601 307-235-8228. 2014 Required Legal Notices and Disclosures Page 11

12. Mental Health Parity & Addiction Equity Act (MHPAEA) Notice • The MHPAEA imposes the following requirements on plans that provide both medical and surgical benefits as well as mental health or substance use disorder benefits: • The financial requirements that apply to mental health or substance use disorder benefits cannot be more restrictive than the predominant financial requirements that apply to substantially all medical and surgical benefits under the Plan, and no separate cost-sharing requirements can be applied only to mental health or substance use disorder benefits. • The treatment limitations that apply to mental health or substance use disorder benefits cannot be more restrictive than the predominant treatment limitations that apply to substantially all medical and surgical benefits under the Plan, and no separate treatment limitations can be applied only to mental health or substance use disorder benefits. • Large plans and self-insured plans are not required to provide coverage for mental health conditions or substance use disorders, but if they do they must comply with the MHPAEA. Small insured plans are required under the Affordable Care Act to provide coverage for mental health conditions and substance use disorders, beginning with the 2014 plan year. Genetic Information Non-Discrimination Act (GINA) In accordance with GINA, this Plan does not deny coverage or benefits, or charge a higher rate or premium, to an otherwise healthy individual found to have a potential genetic condition or genetic predisposition towards a disease or disorder. If PHI is used or disclosed for underwriting purposes, the Plan is prohibited from using or disclosing any of your PHI that is genetic information for such purposes. GINA defines genetic information as that obtained from an individual’s genetic test results, as well as genetic test results of family members and the occurrence of a disease or disorder in family members. 2014 Required Legal Notices and Disclosures Page 12

13. 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, 2014.Contact your State for more information on eligibility – 2014 Required Legal Notices and Disclosures Page 13

14. Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP) 2014 Required Legal Notices and Disclosures Page 14

15. Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP) To see if any other states have added a premium assistance program since January 31, 2014, 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/ebsawww.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 10/31/2016)7.5 2014 Required Legal Notices and Disclosures Page 15

17. PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. • Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to: • All employees. Eligible employees are: Some employees. Eligible employees are: x Employees regularly scheduled to work 30 or more hours per week. • With respect to dependents: We do offer coverage. Eligible dependents are: x A covered employee’s legal spouse. A covered employee’s child(ren). Child(ren) means natural child, adopted child, stepchild, or foster child. See plan document. We do not offer coverage. If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. x ** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here’s the employer information you’ll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

19. PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

20. Automatic Election Process – Flexible Spending Plan CITY OF CASPER FLEXIBLE SPENDING PLAN AUTOMATIC ELECTION PROCESS The City of Casper Flexible Spending Plan utilizes an automatic election process for premium deductions for qualified plans under the City of Casper Flexible Spending Plan. Qualified plans are the City of Casper’s Employee Health Benefit Plan, Delta Dental Plan of Wyoming, the Vision Services Plan (VSP) and AFLAC Hospital Indemnity and AFLAC Accident plans. If you enroll for insurance coverage with these plans, Employee Contributions/Premiums are automatically withheld from your salary pre-tax. You have the right to decline coverage and have no salary reduction for benefits. To exercise this right, you may decline coverage by completing a declination form during the open enrollment process for each of the plans. The open enrollment for the City of Casper Employee Health Benefit Plan, Delta Dental, Flex Plan, VSP Vision Plan, and AFLAC Plans is in the month of September each year. New employees may exercise the right to decline coverage and have no salary reduction during the benefits enrollment period after the hire date and prior to the effective date on the plan (minimum of 30 days, the plans only enroll at the beginning of a month after the 30 day waiting period.) For current premium details please refer to the Employee Health Benefits Booklet or the AFLAC rates sheet on-line at http://www.casperwy.gov under Human Resources and then Employee Benefits. If you do not have Internet access you may request this information from the City’s Human Resources Department. (*Note: Add 20% to the medical premium if you did NOT participate in the annual HRA/blood draw). The Flex Health Reimbursement and Flex Dependent Care Reimbursement plan options are NOT automatic elections. Enrollment must be completed each year by eligible City of Casper Employees during the open enrollment process to enroll for this benefit(s).