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City of Springfield Benefits Summary Annual Benefits Enrollment For Eligible Employees

2022 plan year—March 1, 2022 through February 28, 2023

Due to Covid-19 restrictions, there will not be an open enrollment face-to-face venue. Elimination of the BasicSelect Plan! If currently enrolled in the BasicSelect Plan, you must select another plan through ESS by Wednesday January 12, 2022. Mandatory Partial Online Enrollment through Employee Self Service (ESS) https://ess.springfield.il.us/ if you are making a change, enrolling in Medical, Dental, Vision or enrolling or re-enrolling in the Flexible Spending Account(s).

2022 Annual Open Enrollment for Benefits

January 11th and 12th, 2022

Employee Self Service (ESS) opens for transactions on December 20, 2021 and closes January 12, 2022

~No Face-to-Face Venue~ Procedures slightly different from last year, please read!

Important change: Elimination of the BasicSelect Health Plan effective March 1, 2022 If currently enrolled in the BasicSelect Health Plan, you must select another plan (Point of Service (POS) or the

High Deductible Health Plan (HDHP)) through Employee Self Service (ESS) https://ess.springfield.il.us/ to

continue coverage for you and/or your family March 1st. Transaction deadline January 12, 2022.

If you are enrolling, waiving or making a change to your Health, Dental and Vision plan, you must make that

transaction through Employee Self Service (ESS) https://ess.springfield.il.us/ Deadline January 12, 2022.

If you are enrolling or re-enrolling in the Flexible Spending Account Programs, you must make that transaction

through Employee Self Service (ESS) https://ess.springfield.il.us/ Deadline January 12, 2022.

If you are not making any changes to your POS or HDHP Health Plan, Dental and Vision, you do not have to do

anything. These benefits will continue as your current coverage for the new plan year March 1, 2022.

All enrolled in the health plans will receive a new health ID card this year even if you didn’t make change.

When can I make my transactions in Employee Self Service (ESS)?

Monday, December 20, 2021 through Wednesday, January 12, 2022 up until 7:30 p.m. Are there step-by-step procedures how to navigate through Employee Self Service (ESS)? YES, detailed instructions printed in color located on ESS and a hard copy with your Timekeeper. When is the deadline to make my ESS transactions and turn in my gold payroll form to Human Resources? ESS transactions Wednesday, January 12, 2022 by 7:30p. Gold payroll form same day by 4:30p How do I speak with a MetLife representative to ask questions, enroll, change or cancel policies?

Refer to the MetLife flyer within your packet stating to contact MetLife at 1-888-592-1840, Mon – Fri, 10 am – 7 pm CST, January 3, 2022 – January 12, 2022. DENTAL changes or enrollments must be made through (ESS) https://ess.springfield.il.us/

Reminder: If you are enrolled in the High Deductible Health Plan (HDHP) and participating in the Health Savings Account (HSA), you cannot enroll in the Flexible Spending Unreimbursed Medical program; only enrollment in the Dependent Care program is allowed. If you wish to confirm your annual Wellness and Health Risk Assessment (HRA) was received, contact LeadWell at 217-993-0998, Mon – Thurs, 7a to 5:30p. Plus, confirm your March paycheck provides the correct premium.

It is your responsibility to verify all your deductions on your March paycheck coincide with your enrollment elections! If you see a discrepancy, please contact Human Resources at 217-789-2446 between 8:00a and 4:15p.

Materials, Benefits Booklet, HDHP/HSA Educational slide show, Summary Plan and Announcements are provided on Employee Self Service (ESS) 24/7 at https://ess.springfield.il.us/

CITY OF SPRINGFIELD ANNUAL BENEFITS ENROLLMENT

READ THE FOLLOWING REGARDING THE ENCLOSED GOLD PAYROLL FORM THAT

MUST BE ADHERED TO AND RETURNED TO HUMAN RESOURCES BY 1/12/2022

EMPLOYEES: Annual Payroll Election Form (gold) for Premium Deduction information and Health Savings Account (HSA) contributions. Reverse side of the form is Secondary Health Insurance Coverage Disclosure and Flexible Spending Account Terms & Conditions for Medical & Dependent Care.

ANNUAL GOLD PAYROLL ELECTION FORM -

FRONT SIDE of the gold payroll form includes:

PRE-Tax Deductions (top half of form): Mandatory Employee Self Services (ESS) https://ess.springfield.il.us/online transactions required “if” you are enrolling or making a change to: Health, Dental and Vision. If not making a change in these three plans no action is required. You must enroll or reenroll in the FSA Programs through ESS if you wish to participate March 1, 2022.

The only exceptions are the three lines indicating the HSA options; will continue to be processed via this gold form. Do not confuse the HSA banking with the HDHP health coverage option through ESS if enrolling or making a change. Review the notes next to each line on your gold payroll form for important specific instructions. Once you review and follow through with how you wish to proceed, sign/date the gold form below your current

elected deductions(s) and return to your Timekeeper or the Office of Human Resources (not Payroll) by Wednesday,

January 12, 2022 by 4:30 p.m. Failure to return this gold form will result in continued deduction of premiums for the

HSA contributions and Post-Tax Deductions (bottom half of the form) that is not included through Employee Self Service.

POST-Tax Deductions (bottom half of form): Review your pre-printed benefit options at the bottom half of your form. Read the instructions next to each line to

determine how to proceed to enroll, change, cancel, or if you have a question for the vendor.

These specific benefits are not available through Employee Self Service (ESS) to make your transactions.

Once you have reviewed and followed through with how you wish to proceed, sign/date the gold form below your

current elected deductions(s) and return to your Timekeeper or the Office of Human Resources (not Payroll) by

Wednesday, January 12, 2022 by 4:30p.m. Failure to return this gold form will result in continued deduction of

premiums for the Post-Tax Deduction (bottom half of the form) that is not included through Employee Self Service.

BACK SIDE of the gold payroll form includes:

Secondary Health Insurance Coverage Disclosure: You must complete this section every year if you, your

spouse and/or dependents are covered under the City of Springfield health plan as well as covered under

another health insurance plan (double covered), so Trustmark knows how to adjudicate your claims. Claims

will be held and not processed until Trustmark receives this information. Feel free to contact Trustmark at

800-848-3012 to provide this information as well to avoid claims disruption.

Flexible Spending Account (FSA) Terms & Conditions: If you are re-enrolling or brand new to these programs,

you MUST enroll through Employee Self Service (ESS) https://ess.springfield.il.us/ by Wednesday, January 12,

2022 at 7:30 p.m. Failure to enroll online will forfeit your right to enroll in the unreimbursed medical and

dependent care flex accounts for the plan year March 1, 2022 through February 28, 2023. No exceptions!

Note: If you enroll in the HDHP and participate in the Health Savings Account (HSA), you cannot enroll in the Flexible

Spending Unreimbursed Medical program; only the Dependent Care program.

Human Resources Secured Drop Off Box- You can drop off your forms on the first floor of the MCW building and place

in the HR secured blue metal drop box between the security booth and the elevators. Please wear mask entering bldg.

Deadline 1/12/2022 -Making a change to your health, dental, & vision plan? MUST make those changes in ESS. -Not making a change in those three plans? No transaction is required. -Reminder: BasicSelect Health Plan eliminated 3/1/22. You MUST elect another health plan to ensure coverage for you and your family. -Must enroll or re-enroll in FSA programs through ESS each year.

Important Updates

EMPLOYEE SELF SERVICE (ESS) –

https://ess.springfield.il.us/ <View the full

Benefits Booklet and Plan Document on ESS.

ESS is a helpful resource to view current benefit

information throughout the year.

You do not need a login to view benefit information

on ESS.

-If you are making a change, or enrolling in

health/dental/vision and enrolling or reenrolling in

the FSA Programs, you must make transactions in

ESS.

METLIFE – See important instructions in your Open

Enrollment packet.

Designating or confirming your LIFE insurance

beneficiary www.benefitsconnect.net/springfieldil

Instructions:

https://ess.springfield.il.us/LifeInsurance.aspx

Details on the DENTAL plan coverage

https://ess.springfield.il.us/BenefitsDental.aspx

MetLife also offers Ancillary products: Cancer,

Critical Illness, Hospital Indemnity, Accident,

Supplemental Life and AD&D. View video and plans

https://benefittalk.metlife.com/cityofspringfield

FLEXIBLE SPENDING ACCOUNTS

ConnectYourCare (CYC)/Optum – If you enroll in

the Health Savings Account (HSA) you cannot

enroll in the Flexible Spending Account (FSA)

Healthcare program; only the Dependent Care

program. Details on ESS. New enrollee-

CYC/Optum Debit card will arrive end of February.

LEADWELL CLINIC – Utilize the no-cost COS

LeadWell Clinic. You must be a covered member

under the COS health plan to utilize LeadWell.

Review literature on ESS.

PRESCRIPTIONS – If possible, avoid filling your

prescriptions Friday afternoon through Sunday.

If you encounter an issue, your Provider and Elixir

are generally unable to rectify any problems

during this timeframe. Note: request 90 day fills

on maintenance drugs to avoid penalties.

HEALTH INSURANCE –

BasicSelect Health Plan eliminated 3/1/22.

Choose another plan through ESS.

All enrolled will receive a new ID card and will

arrive before the first week of March. Please

provide your new card information to your

pharmacy and health providers when seeking

services; discard old cards.

HEALTH INSURANCE PREMIUM SAVINGS OF 10%

– Employees and Spouses participating in the COS

health plan must schedule a Biometric Wellness

Screen which includes a blood screening and

complete an online Health Risk Assessment (HRA)

http://www.hshsmedicalgroup.org/wellsource

by December 30th of each year to receive the

10% discount on your health insurance premium.

You do not have to wait a full exact year to

complete another screening. Try to complete

within your birthday month. Meeting with the

LeadWell Health Coach is encouraged.

Instructions on how to complete your online HRA

can be found within the HSHS link above.

Using LeadWell for these services is strongly

encouraged to save you and the health plan

significant dollars.

If you must seek your own provider for these

services, there is an option while completing your

HRA to download the Wellness form for your non-

LeadWell provider to complete and fax to

LeadWell at 217.529.4228. LeadWell is our

mechanism to track both requirements

(Wellness/labs/HRA).

Have your labs completed at LeadWell even if you

seek a non-LeadWell provider for significant cost

savings for you and your employer.

If you are single on the HDHP and want the $500

Employer HSA contribution, you must utilize

LeadWell.

The Open Enrollment materials include only a summary of benefits. Please refer to the Benefits Booklet and Plan Document for full details https://ess.springfield.il.us/BenefitsHealth.aspx

PAYCHECKS AND PREMIUMS - Check your first paycheck in March to confirm premiums and coverage are correct for the elections

you are enrolled in. You will be responsible for missed premiums. Premium amounts are located within your packet for verification.

HEALTH SAVINGS ACCOUNT (HSA) (for High Deductible Health Plans only)

Very important to establish your account prior to Open Enrollment in order to utilize your Health Savings Account (HSA) beginning in March 2022. Continue reading so there are no surprises.

Need help setting up your HSA account?

Bottom of this page are just a few local banks ready to assist you, but feel free to contact your own bank for your HSA needs. YOU are responsible for setting up your own HSA account prior to open enrollment.

Extremely important: Once you establish your HSA account, please provide all HSA forms to the Office of Human Resources by Wednesday, January 12, 2022 at 4:15 p.m. You must have your HSA routing and account number on the bank’s letterhead prior to turning in to the Human Resources representatives.

Take action! It is very important to inform your bank that funds will not be deposited in to your HSA until your first paycheck in March if you are contributing to your HSA; and the end of March for the Employer contribution to your HSA. Ask your bank if a small deposit is required to keep your account active awaiting deposits. Banks tend to close an HSA account after a period of time with a zero balance, causing your first deposit from your paycheck to reject and incur a fee. This is an immense inconvenience for you and COS if account is not active upon deposit.

Note: You must participate in the City’s High Deductible Health Plan (HDHP) to be eligible to participate in the Health Savings Account (HSA) - both effective March 1, 2022.

Per the IRS: you cannot be enrolled in a spouse’s non-HDHP plan and have an HSA account. Also, seek a tax advisor several months prior to reaching age 65 or Medicare eligible if enrolled in an HSA for guidance.

IMPORTANT: Effective March 1, 2022 - neither the City nor you can contribute to your HSA account until you have established your HSA account. You cannot use HSA funds until you establish your account. When you request claims reimbursement, the date of service for claims must coincide with the date you establish your HSA account. Example: If you have a claim in March/April 2022, but you do not set up your HSA account until May 2022, you

cannot be reimbursed for March/April 2022 claims. You can only utilize your funds for claims starting May 2022 when you established your HSA account. Claims reimbursement is through your HSA bank, NOT the City. Consult with your HSA bank of choice for details.

Are you NEW to the HDHP 3/1/22? Great! You are eligible to receive the full City’s Health Savings contribution of ($500.00 single/$2,000 family) the first year only deposited to your own established HSA account by March 31, 2022. You must set up your own HSA by March 1st.

Important: Single HDHP plan participants must complete a Biometric Wellness Screen (includes labs-finger stick) at LeadWell Clinic on 6th Street and complete an online Health Risk Assessment (HRA) each year to receive the $500 Employer contribution.

HRA link- http://www.hshsmedicalgroup.org/wellsource

Note: If you are newly enrolled in the COS health plan and a new patient to LeadWell, you must be set up in LeadWell’s system prior to seeking an appointment at LeadWell or completing your HRA. Contact COS Human Resources and ask a Benefits Representative to assist you at 217-789-2446 between 8:30a and 4:15p.

Total Employee and Employer contributions to the HSA to avoid going over the IRS maximums are:

$3,650 Single plan $7,300 Family plan $1,000 Additional age 55 and over

Review the EDUCATIONAL SLIDE SHOW on ESS for more information https://ess.springfield.il.us/BenefitsHealth.aspx

Institution Phone# Bank of Springfield 217-241-6166 Town and Country Bank 217-321-3437 Hickory Point Bank & Trust 217-547-3607 Carrolton Bank 217-793-8696 Illinois National Bank 217-747-5576 United Community Bank 217-787-3000 Marine Bank 217-525-8800/726-0602 Prairie State Bank 217-993-6260/547-7158

The Summary of all Benefits, Plan Document, Compliance Notices and the Education slide show information is available to view by accessing online through Employee Self Service (ESS) https://ess.springfield.il.us/ If this option is not doable, please request a benefits booklet for viewing from your Timekeeper or the Office of Human Resources/Benefits Department at 217.789.2446.

**Please be mindful of the deadlines and thank you for your continued cooperation during 2022 Annual Enrollment.**

REFER TO YOUR GOLD PAYROLL FORM FOR SPECIAL CONTACTS AND PHONE NUMBERS DURING THIS OPEN ENROLLMENT ONLY!

Important Changes Effective March 1, 2022

BASICSELECT Plan is eliminated. To continue coverage you must select either the Point of service

(POS) or the High Deductible Health Plan (HDHP) plan to ensure coverage for you and/or your family 3/1/22. How do I compare the plans: Refer to the Schedule of Benefits (SBC’s) in your packet and the education slide show on Employee Self Service (ESS) https://ess.springfield.il.us/

POS Plan will have the following plan changes:

• New tier 1 & tier 2 deductible

$350 individual / $1,050 family

New (plan member) coinsurance

20% tier 1 and 25% tier 2

• New tier 1 & tier 2 out-of-pocket (includes deductible)

$1,350 individual / $4,050 family

New office visit copays

PCP $30 copay / Specialist $50 copay

• New office and outpatient LAB copay; $100 copay

(Labs performed at Leadwell clinic will continue to be no charge)

• New prescription drug copays

• Retail 30-day supply (Generic / Preferred / Non-Preferred)

$15 copay / $25 copay / $45 copay

• Retail 90-day supply (Generic / Preferred / Non-Preferred) $45 copay / $75 copay / $135 copay

• Mail Order 90-day supply (Generic / Preferred / Non-Preferred) $37.50 copay / $62.50 copay / $112.50 copay

HDHP/HSA – Employees enrolling new to the HDHP for 3/1/22 will be eligible to receive the full City’s

Health Savings Account (HSA) Employer Contribution amount first year only of ($500 employee/$2,000 family). The full contribution amount will be made to your own established HSA account by March 31, 2022. Deadline to set up your HSA account is March 1st.

Choice of plan options: March 1, 2022

SUMMARY ONLY - see Summary of Benefits in the Benefits Booklet or Plan Document for details on Employee Self Service

(ESS) https://ess.springfield.il.us/

High Deductible Health Plan (HDHP)

Single $500 HSA Contribution only w/Wellness at

LeadWell & HRA/Family $2,000 HSA Contribution

Point of Service

Network HealthLink/PHCS PPO HealthLink Provider Level 1 & 2 | & PHCS

Deductible (Member responsibility)

Individual (Provider Level 1 & 2 / Out-of-Network) Family (Provider Level 1 & 2 / Out-of-Network)

$2,800 | $5,600

$5,600 | $11,200 Includes Medical and Rx

$350 | $500

$1,050 | $1,500

Coinsurance (Co-ins (%) – Member responsibility)

Provider Level 1 & 2 / Out-of-Network

N/A

20% / 25% / 30%

Out-of-Pocket Max (Member responsibility) Individual (Provider Level 1 & 2 / Out-of-Network)

Family (Provider Level 1 & 2 / Out-of-Network)

$2,800 | $11,200 $5,600 | $22,400

Includes Medical and Rx

$1,350 | Unlimited $4,050 | Unlimited

Includes Medical Deductible and Medical Copays and Co-ins (%)

Physician Services (In-Network) Well Adult / Well Child Physician Office Visit Specialist Office Visit

X-Rays Diagnostics Urgent Care

Labs Outpatient

Plan pays 100%

Deductible; then plan pays 100% Deductible; then plan pays 100% Deductible; then plan pays 100% Deductible; then plan pays 100% Deductible; then plan pays 100%

Plan pays 100%

$30 copay; deductible; then Co-ins (%) $50 copay; deductible; then Co-ins (%) $50 copay; deductible; then Co-ins (%) $50 copay; deductible, then Co-ins (%) $100 copay; deductible, then Co-ins (%)

Inpatient Hospital Deductible (& member pays co-ins (%)

(per admission) In-Network (Provider Level 1 & 2)

Deductible; then plan pays 100% Deductible; the Co-ins (%)

Emergency Room Deductible; then plan pays 100% $250 copay; deductible; then Co-ins (%)

Prescription Drugs (Retail –34 days) Generic / Formulary / Non-Formulary

Note: Higher copays apply for retail 84-90 days; see full details on Employee Self Service within the Benefit Booklet.

In-Network Deductible; then pays 100% Out-of-Network: No Coverage

Rx Deductible: $50 individual /$150 family

Max out-of-pocket for Rx Cost: In-Network: Rx Individual $1,000/

Rx Family $3,000 Out-of-Network Rx-No Coverage

In-Network Copays: $15 / $25 / $45 / $50

Prescription Drugs (Mail Order –90 days) Generic / Formulary / Non-Formulary

In-Network Deductible; plan pays 100% Out-of-Network: No Coverage

In-Network Only Copays:

$37.50/ $62.50 / $112.50 (Rx Deductible and Max Rx out of pocket

applies-see Rx above)

Lifetime Maximum Unlimited Unlimited

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Inside This Guide

Benefits Overview 10

Wellness Savings 11

COS Leadwell 14

Medical Insurance 17

Pharmacy Coverage 18

HealthLink Network 20

Where to Seek Care 21

How to Save Money 22

Dental Insurance 23

Vision Insurance 24

Flexible Spending Account (FSA) 25

Basic Life and AD&D 27

Voluntary Life and AD&D 27

Accident Insurance 28

Critical Illness Insurance 29

Hospital Indemnity Insurance 30

Cancer Insurance 30

Health Screening Benefits 31

Short & Long-Term Disability 31

Pet Insurance 32

Employee Premiums 33

Retiree Premiums 34

Voluntary Life and AD&D 35

Accident/Critical Illness Premiums 36

Hospital Indemnity Premiums 36

Cancer Premiums 37

Benefit Resources & Contact Information 38

Credit Union 39

NCPERS Life and AD&D 40

Annual Notices 41

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Benefit Options

BasicSelect Plan - Eliminated

Medical Insurance with Trustmark and Prescription Drug coverage with Elixir

• Point of Service (POS)

• High Deductible Health Plan / Health Savings Account (HSA)

Dental Insurance with MetLife

Vision Insurance with UniCare

Life Insurance and Accidental Death and Dismemberment Insurance with MetLife

• Basic Life and Accidental Death and Dismemberment Insurance

• Voluntary Life and Accidental Death and Dismemberment Insurance

Flexible Spending Account (FSA) with Connect Your Care, now part of Optum

Financial

• Health Care Flexible Spending Account

• Dependent Care Flexible Spending Account

Ancillary Benefits with MetLife

• Accident

• Cancer

• Hospital Indemnity

• Critical Illness

Benefits Overview

City of Springfield offers comprehensive benefits to meet the needs of you and your family. Please review this benefits guide to understand your benefits, in order to make the best decision for you and your family.

This guide provides highlights of the City of Springfield, IL benefits program.

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Wellness Savings

Employees newly enrolling in the High Deductible Health Plan will receive the full amount of City’s Health Savings Account contribution by March 31, 2022, the first year of enrollment; $500 contribution for single coverage or $2,000 contribution for family coverage. To qualify for the City’s contribution, Health Risk Assessment and Biometric Screening must be performed at Leadwell clinic. Any contributions made by the City to your Health Savings Account during the second year of enrollment will be prorated and contributed at the end of each month, the entire City contribution amount will not be available at the beginning of the second enrollment plan year. Employees currently enrolled in the HDHP with single coverage, electing to continue their enrollment in the HDHP will continue to receive the City’s prorated contribution at the end of each month, if Health Risk Assessment and Biometric Screening are completed by December 30, 2022.

Employees currently enrolled in the HDHP with family coverage, electing to continue their enrollment in the HDHP will continue to receive the City’s prorated contribution at the end of each month. To save money and take advantage of 2023 family Wellness rates, Health Risk Assessment and Biometric Screening must be completed by December 30, 2022.

Biometric screenings performed at Leadwell Clinic are FREE! Schedule your appointment during your birthday month.

COS LeadWell Clinic

Hope Pavilion

5220 S. 6th Street Frontage Road, Suite 1400

Monday – Thursday: 7:00 a.m. to 5:30 p.m.

Phone Number: 1-217-993-0998 Fax Number: 1-217-529-4228

Save 10% on your health insurance premium by following the steps below to complete your online Health Risk Assessment (HRA) and schedule your Biometric Screening with the LeadWell Health Coach or your primary care provider (PCP).

1. To begin your HRA visit www.HSHSMedicalGroup.org/WellSource.

2. Click on the Health Risk Assessment link.3. Enter your username.

Employee: Username is your City of Springfield username. Spouse: Username is employee username with “s” at the end to designate spouse.

Example: Employee username: bjohnson Spouse username: bjohnsons

4. Enter your password. Returning users: Enter password from previous WellSource registration. New users: Use password provided by COS HR; upon registration you will be prompted to change your password.

5. Complete the questionnaire.6. Return to

www.HSHSMedicalGroup.org/WellSource, and click the link to schedule your Biometric Screening with the LeadWell Health Coach, or call 217-993-0998.

SAVE 10% ON YOUR HEALTH INSURANCE PREMIUMThe LeadWellTM Clinic is here to help! Schedule your no-cost Health Risk Assessment and Biometric Screening today!

Notice to City of Springfield employees and spouses participating in the City’s HDHP/HSA plan: The City is not providing advice on whether and to what extent receiving near-site clinic services may impact HSA eligibility. Individuals should consult with their tax advisor with any questions or concerns. You may also visit the IRS link pertaining to the IRS tax guidance on HSAs at irs.gov and search for IRS Notice 2008-59 for IRS guidance on HSAs and IRS Publication 969 on HSAs and other tax-favored health plans.

5220 S. 6th St. Frontage Rd. Suite 1400 (within Hope Pavilion) Springfield, IL 62703ph: 217-993-0998 • f: 217-529-4228Hours: Monday - Thursday, 7 a.m. - 5:30 p.m.

Eligibility RequirementsTo be eligible to receive 2023 health insurance premium savings of 10%, BOTH participating employee and spouse must complete the HRA and Biometric Screening by December 30, 2022.

New hires or new to health plan: In order to receive premium savings, complete these two requirements within 60 days. Single on the HDHP, you must complete your screening at LeadWell to receive the employer $500 contribution to your HSA.

You do not have to wait a full year from your previous HRA and Biometric Screening to complete these requirements. We recommend scheduling during your birth month.

If you wish to seek services with your PCP, download and print the Biometric Form PDF by visiting www.HSHSMedicalGroup.org/WellSource and have your PCP complete at your visit. This form must be returned to the LeadWell Clinic or faxed to 217-529-4228 by December 30, 2022.

Questions?Please contact Human Resources/ Benefits at 217-789-2446.Read more on the next page.

What is a Health Risk Assessment (HRA)?The confidential HRA between you and LeadWell is a general health online questionnaire that assesses what areas you are doing well and what areas you may need to improve.

What is a biometric screening?A biometric screening is a preventive health screening that assesses your cholesterol and glucose (consisting of a finger stick), blood pressure, waist circumference and body fat percentage.

Is it required to see the health coach in order to receive the 10% premium discount?No, you have the option to be seen by either the LeadWell health coach or your primary care provider to receive your premium discount.

What are the benefits of seeing the health coach to complete the biometric screening?An appointment with our health coach is at no cost to you.The health coach conducts biometric screenings and follow-up consultations regarding the biometric screening and health risk assessment results. The purpose of our health coach is to help guide you toward living a healthier lifestyle.

Am I required to fast before my biometric screening?No, you are not required to fast before your biometric screening. However, it is recommended that you fast about 9-12 hours prior — refraining from food and drink with the exception of water, unsweetened tea or black coffee.

Do I need to have a full lab draw and a physical with a provider?No, a full lab draw and wellness exam with a LeadWell advanced practice registered nurse (APRN) is optional and is no longer a requirement to receive the premium discount.

FREQUENTLY ASKED QUESTIONS

City of Springfield provides LeadWell services to health plan members (ages 5 & up) at low to no cost. Choose LeadWell for convenient access to the high-quality patient-first care you know and trust.

5220 S. 6th St. Frontage Rd.Suite 1400, Springfield, IL ph: 217-993-0998 • f: 217-529-4228 Hours: Mon. - Thurs., 7 a.m. - 5:30 p.m.

HSHS Illinois Building 850 E. Madison St., Springfield, IL ph: 217-744-WELL • f: 217-528-9995 Hours: Mon. - Fri., 6 a.m. - 6 p.m.*Monday-Thursday $10 convenience fee applies

Diagnosis and Medical Care• Bladder infections• Bronchitis• Ear infections• Minor rashes • Mononucleosis• Pink eye• Ringworm• Sore throats• Sinus infections• Sprains and strains• Swimmer’s ear• Wart removal • Wound infections

Preventive Care/ Wellness Services

• Flu shots• Immunizations• Health screenings• Physical exams• Skin screenings• School physicals• Sports physicals• TB testing

Other Services• Lab work• Rapid screen

diagnostic tests• COVID-19 tests

LeadWell is here to help. Call to schedule your appointment today.

Walk-ins welcome!

LEARN MORE hshsmg.org/leadwell

Photo ID and proof of insurance

required. To protect those around you, please wear a face covering.

Notice to City of Springfield employees and spouses participating in the City’s HDHP/HSA plan: The City is not providing advice on whether and to what extent receiving near-site clinic services may impact HSA eligibility. Individuals should consult with their tax advisor with any questions orconcerns. You may also visit the IRS link pertaining to the IRS tax guidance on HSAs at irs.gov and search for IRS Notice 2008-59 for IRS guidance on HSAs and IRS Publication 969 on HSAs and other tax-favored health plans.

Feel Better FASTER.

Why Choose HSHS Medical Group - Leadwell?

LeadWell offers convenient, high-quality, patient-first care you know and trust from HSHS Medical Group tailored to meet the needs of employees and dependents of The City of Springfield. Laboratory services available. Visits to LeadWell are at low to no cost to the patient. The City of Springfield provides LeadWell to its health plan members as a benefit. Utilizing LeadWell lowers claims under The City of Springfield’s medical plan – helping to keep plan costs down when determining future insurance rates. LeadWell clinics are staffed with licensed HSHS Medical Group nurse practitioners/advanced practice registered nurses (APRN), medical assistants, and patient service representatives who are committed to providing patient-first care. LeadWell clinics are overseen by a physician who collaborates with all providers.

ADDITIONAL SERVICES: External Lab Orders Lab orders from any provider can be performed at LeadWell at no cost to the patient. Lab results are sent to the ordering provider, who will then contact the patient to discuss. Chronic Condition Management LeadWell – 5220 S. Sixth St. can assist in the management of certain chronic conditions; including asthma, anxiety/depression, diabetes, high cholesterol, and high blood-pressure. Please contact 217-993-0998 for more information. Virtual Visits Virtual Visits with LeadWell providers are available during operating hours. Please call to schedule a virtual visit appointment. COVID-19 Testing and Care LeadWell is able to care for patients with respiratory illness. Processes and procedures for sanitization and personal protective equipment are consistent with HSHS Medical Group guidelines. COVID-19 PCR testing is available.

Prescription Services LeadWell providers have the capability of prescribing medications to patient’s pharmacy of choice. LeadWell providers are also able to offer select prescriptions on-site at no cost to the patient. (Prescriptions ordered by non-LeadWell providers are not able to be filled at LeadWell.) Injection Administration LeadWell is able to administer select injections provided the medication is delivered directly to the clinic by a licensed pharmacy delivery service. Please contact LeadWell to determine eligibility. Referrals LeadWell providers are able to refer to other providers and specialists for any medical service not offered within the clinic. Services referred outside of LeadWell will be billed to patient insurance. WRAP-AROUND/ AFTER HOURS CARE: HSHS Medical Group offers several options for care outside of LeadWell’s operating hours. HSHS Medical Group Walk in Clinic – Meijer 4200 Conestoga Dr - Suite 101 LeadWell services are available at HSHS Medical Group – Meijer on Saturday and Sunday at no cost. Please inform the staff you are arriving for a LeadWell visit. Visits Mon-Fri will be billed to patient insurance.

HSHS Medical Group Priority Care - South MacArthur 1836 S. MacArthur Blvd. 8 a.m. - 8 p.m., 7 days per week Visits will be billed to patient insurance. Anytime Care $49 Virtual Visit Available 24/7 www.anytimecare.com 844-391-4747 CONTINUITY OF CARE HSHS Medical Group Primary Care Provider (PCP) Any service provided at LeadWell is automatically communicated with your HSHS Medical Group PCP through the electronic health record system, myHSHS. Non-HSHS PCP Upon request, LeadWell will communicate any services to the PCP of patient’s choice. Need a Primary Care Provider? Contact HSHS Medical Group’s Patient Advocate, who can assist in establishing a PCP that best meets the needs of you and your family. Call 833-973-0343.

Call LeadWell for more information!

HSHS Anytime Care can treat avariety of minor conditions,including:

Simple to UseAvailable 24/7 online atanytimecare.com or byphone: 844-391-4747

HSHS Anytime Care Appavailable. Download ourfree app on iOS andAndroid devices.

• Allergies• Asthma• Bug Bites• Cold• Congestion• Diarrhea• Fever• Flu• Headache• Minor Burns and Cuts

• Pink Eye• Rash• Sore Throat• Urinary Tract Infection• Sinus Infection• Sprains• Vomiting

Not feeling well?Use Anytime Carefor only $49 per visit!

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BasicSelect Plan - Eliminated Must select POS or HDHP through ESS by Tuesday, January 12, 2022 to continue health coverage. Point of Service Plan (POS) Tier 1 is the HealthLink network. When eligible services are rendered by a HealthLink provider Tier 1 benefits will apply. Tier 2 is the PHCS multi-network. When eligible services are rendered by a PHCS provider Tier 2 benefits will apply. All others will be considered out-of-network. High Deductible Health Plan (HDHP) / Health Savings Account (HSA) HealthLink is the network. When eligible expenses are rendered by a HealthLink provider in-network benefits will apply. All others will be considered out of network. HSA bank accounts are paired with the HDHP allowing you to set aside money on a tax-free basis to pay for out-of-pocket qualified medical, dental, and vision expenses throughout the year or in the future. You own the money in your HSA account and it is yours to keep – even if you change plans or retire. HSA bank account funds roll over from year to year to be used when you really need them.

Medical Insurance | Trustmark

Choice of medical plans Point of Service Plan High Deductible Health Plan

Out of

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

Network Tier 1

HealthLink Tier 2

PHCS MultiPlan

HealthLink/PHCS MultiPlan

Deductible Individual / Family

$350 / $1,050

$350 / $1,050

$500 / $1,500

$2,800 / $5,600

$5,600 / $11,200

Coinsurance 20% 25% 30% 0% 20%

Out-of-Pocket Max Individual / Family

$1,350 / $4,050

$1,350 / $4,050

Unlimited / Unlimited

$2,800 / $5,600

$11,200 / $22,400

Physician Services Well Adult / Well Child PCP Office Visit Specialist Office Visit

$0 copay

$30 copay $50 copay

$0 copay

$30 copay $50 copay

Not Covered

Deductible then 30% Deductible then 30%

No Charge

Deductible then 0% Deductible then 0%

Not Covered

Deductible then 20% Deductible then 20%

Labs (excluding Inpatient)

$100 copay then 20%

Deductible then 0% $100 copay then 25%

$100 copay then 30%

Deductible then 20%

Emergency Room $250 copay then 20% after Tier 1 deductible Deductible then 0%

Prescription Deductible Individual / Family

$50 / $150

$50 / $150

Not Covered

N/A

N/A

Prescription Drugs Generic Formulary Non-Formulary

Copays: $15/$45 $25/$75

$45/$135

Copays: $15/$45 $25/$75

$45/$135

Not Covered

Deductible then 0% Deductible then 0% Deductible then 0%

Not Covered

Prescription Out-of-Pocket Max Individual / Family

$1,000 / $3,000

Not Covered

Included in Medical OOP

Not Covered

Contributions: Employee

Only Family

City of Springfield will contribute $500* $2,000

You can contribute up to an additional $3,150 $5,300

2022 Maximum IRS HSA Contributions $3,650 $7,300

Catch-Up Contribution (Age 55+) Additional $1,000

*For eligibility , see page 4

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Where to Seek Care

Use In-Network Doctors, whenever possible Pay the lowest cost for care by using in-network doctors, clinics, hospitals and pharmacies. The health plan covers less of the cost when services are provided by out-of-network pro-viders. Choose the Right Type of Care When you need care, know your options: » Leadwell Clinic provides care at no cost to City of Springfield employee and their

family members, ages 5 and up, who are enrolled in a City medical plan.

» Virtual visits, doctor visits, or a call to your primary care physician’s office can save time and money.

» Urgent Care facilities can offer quick convenient care for non-threatening injuries and illnesses that cannot be treated at a doctor’s office after hours when your doctors office is closed and on the weekends.

» Emergency Rooms should be used to treat life-threatening injuries or illnesses. If you have a life-threatening problem call 911 or go straight to the nearest hospital emergency room. In the emergency room, unless your life is in danger, you may have to wait a period of time to be seen. The emergency room is usually the most expensive option for care.

Go to Emergency Room Go to Urgent Care

Heart attack or stroke Moderate fever

Chest pain or intense pain Colds, cough or flu

Shortness of breath Bruises and abrasions

Severe abdominal pain Cuts or minor lacerations

Head injury or other major trauma Minor burns and skin irritations

Loss of consciousness Eye, ear, or skin infections

Major burns or severe bleeding Sprains or strains

One-sided weakness or numbness Possible fractures

Open fractures Urinary tract infections

Poisoning or suspected overdose Respiratory infections

Emergency Room versus Urgent Care

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Services at Leadwell clinic are FREE!

Make your appointment today.

Hope Pavilion

5220 S. 6th Street Frontage Road

Suite 1400 Monday – Thursday: 7:00 a.m. to 5:30 p.m.

Phone Number: 1-217-993-0998

Use Your Preventive Care Benefits

Preventive care annual physical exams can be performed at any time during the plan year. In addition to annual physical exams with primary care physician, annual well-woman exams are covered at 100%.

Preventive care exams are covered at 100% as long as your physician participates with your network and the visits are coded as preventive. Getting regular exams, screenings and immunizations can save you a lot of money in the long run by catching concerns early or preventing them all together.

High-Cost Scans, X-Rays and Tests

MRI, PET scans, CT scans etc. are nearly 2/3 less costly at free-standing, in-network imaging centers than at hospitals. Whenever possible, compare cost options prior to scheduling your necessary services.

Ask Your Doctor for Generic Drugs

Ask your doctor if there is a generic version of any medication you are prescribed. Take advantage of Prescription Savings Programs at major retailers. Ask about free samples from your doctors and/or manufacturer rebates.

To view the prescription drug list, login to the portal: https://www.medtrakrx.com/Register/Login

Search Good Rx for Lower Prices

Drug prices can sometimes vary significantly between pharmacies. Access Good Rx at goodrx.com to find the lowest price pharmacy near you and/or print FREE coupons.

How to Save Money! When using your Medical and Prescription Plans

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Dental Insurance | MetLife Preferred Provider Organization (PPO) The PDP Plus Plan allows the flexibility to use any dentist, in or out-of-network. Staying in-network will allow your annual maximum to last longer. If you visit a dentist out-of-network, you will pay additional charges and you may be responsible for paying the bill at the time of service and receiving reimbursement later. Preventive Services: • Cleanings (once every 6 months) • Exams (once every 6 months) • Bitewing X-rays (1 per year) • Fluoride

• Sealants

Access and manage your benefits:

• Find a network dentist

• Access your ID card

• View your Plan Summary

• View your claims

Or go online at www.metlife.com/mybenefits.

Choice of dental plans Basic Plan

In Network / Out of Network Enhanced Plan

In Network / Out of Network

Network Name PDP Plus PDP Plus

Annual Plan Maximum $1,000 Per Person / $1,000 Per Person $2,000 Per Person / $2,000 Per Person

Deductible $75 Per Person / $75 Per Person $50 Per Person / $50 Per Person

Preventive Services Plan Pays 100% / Plan Pays 100% Plan Pays 100% / Plan Pays 100%

Basic Services Plan Pays 80% / Plan Pays 70% Plan Pays 90% / Plan Pays 80%

Major Services Plan Pays 50% / Plan Pays 50% Plan Pays 60% / Plan Pays 50%

Orthodontia Lifetime Maximum $1,000 Per Person / $1,000 Per Person $1,000 Per Person / $1,000 Per Person

Orthodontia Eligibility Adults and Child(ren) to age 19 Adults and Child(ren) to age 19

Orthodontia Services Plan Pays 50% / Plan Pays 50% Plan Pays 50% / Plan Pays 50%

Basic Services: • Fillings • Simple extractions • Root canals • Periodontics • Oral Surgery

Major Services: • Implants • Dentures/bridges/partials • Crowns

Download MetLife’s Mobile App

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Vision Insurance | UniCare

Vision insurance helps offset the costs of routine eye and also helps pay for correction eye wear, eyeglasses and contacts, prescribed by an eye-care

accessing in-network vision providers, able to maximize savings. If you visit an out-of-network vision provider, you will be responsible for paying the bill at the time of service. You may submit the out-of-network claim for reimbursement after your visit.

Eyeglass lenses upgrades: Members can choose to upgrade their new eyeglass lenses at a discounted cost when purchasing eyewear from a UniView Vision network provider. Additional Pair of Glasses: Receive up to 40% off retail price for an additional pair of glasses from any UniView Vision network provider. Eyewear Accessories: Receive up to 20% off retail price when purchasing non-prescription sunglasses, lens cleaning supplies, contact lens solutions, eyeglass cases and more at UniView Vision network providers. Conventional contact lenses: Receive up to 15% off retail price after covered benefits have been used. UniCare’s Special Offer Program: Receive discount offers on LASIK surgery and much more by visiting www.unicare.com.

Vision Plan Details: Frequency In-Network Out-of-Network

Network UniView Vision

Eye Exam Once every calendar year $10 copay Up to $35 reimbursement

Lenses - Single vision - Bifocal - Trifocal

Once every calendar year $15 copay Reimbursement varies

Frames Once every 2 calendar year $120 allowance, then 20% off any remaining balance

$45 max reimbursement

Elective Contacts (disposable)

Once every calendar year $105 allowance $105 max reimbursement

©2018 ConnectYourCare, LLC. All Rights Reserved.

ConnectYourCare (CYC)/Optum Financial Flexible Spending Account (FSA)

The City of Springfield’s Unreimbursed Medical and Dependent Care Flexible Spending

Account (FSA) programs are administered by ConnectYourCare/Optum Financial. If you elect to participate, waive or change

your contribution amounts in one or both of these programs effective March 1, 2022, you must make your transactions through

COS Employee Self Service (ESS) https://ess.springfield.il.us/ between 12/20/2021 and 1/12/2022.

If you have any questions regarding the programs, please call the representative at 1-913-449-2663 during the two-day Open

Enrollment event on Tuesday, January 11th and Wednesday, January 12th, 2022 from 8:00 a.m. to 6:00 p.m. Please make sure

you understand this program prior to signing up. Once enrollment ends, please revert back to using 1-888-339-3685.

If you are a current participant and elect to re-enroll, you must re-enroll through the online COS Employee Self Service (ESS)

https://ess.springfield.il.us/ between 12/20/2021 and 1/12/2022. Failure to re-enroll or make changes through ESS will forfeit

your participation. Check your first March paycheck to confirm election amounts are correct.

What CYC/Optum offers and IMPORTANT information you need to be aware of PLEASE READ – Do not indicate after enrollment you were not informed

o Website – The ConnectYourCare website offers many enhanced features. You can set up direct deposit reimbursements by

providing your bank account information, use your e-mail to receive up-to-date account and claims status information and

access account activity statements. The site also has the ability to upload claims or receipts to verify your debit card purchases

and a feature called “Pay My Provider” that works like an online bill pay service where you can trigger a payment directly from

your Unreimbursed Medical and/or Dependent Care FSA account(s) to a provider for services that have been rendered.

o Customer Service – The CYC customer service team is available 24 hours per day, 7 days per week at 888-339-3685.

o Debit Card – For the 2022-2022 Plan Year, new participants will receive a CYC/Optum debit card around the end of February.

Upon receipt, you will have the option of ordering additional cards, at no cost to you, for your eligible dependents by logging

into your account or by contacting CYC/Optum Customer Service. More detailed information will be provided once you receive

your card. Make sure you call the number on your card to register it, or services will be denied.

VERY IMPORTANT: Debit card swipes for payment starting March 1, 2022, can only be utilized for “dates of services” that

are incurred from March 1, 2022 through February 28, 2023 – no exceptions. Do no swipe your card for prior year’s services

or you will have to pay it back.

o Pay Me Back – Some expenses are easier to pay upfront and then get reimbursed from your Unreimbursed Medical and/or

Dependent Care FSA account(s). Using the Reimburse Myself feature, you can be reimbursed by submitting a claim form with

supporting documentation to CYC/Optum.

o Pay My Provider – You may want to take advantage of the Pay My Provider feature if you have regular monthly expenses

such as childcare, orthodontia, etc. CYC/Optum can send these providers a check directly from your Unreimbursed Medical

and/or Dependent Care FSA account(s) each month.

o Mobile Access Site – The mobile application for iPhone, Android and Blackberry users allows enrolled participants on-

demand access to account balance information.

o Submit claims directly from your Smart Phone - The application, EZ Receipts, will enable you to submit Unreimbursed and/or

Dependent Care FSA account claims and upload receipts for unverified FSA debit card transactions from the palm of your hand.

o

$500 Carryover Provision - Participants will be able to carry over a minimum of $22.50 up to a maximum of $500 of their

unused ConnectYourCare Healthcare FSA account balance remaining at the end of a plan year.

How Much You Can Contribute

You can contribute a plan year minimum of $120 and a maximum of $2,500 to your Unreimbursed Medical FSA and a

maximum of $5,000 to your Dependent Care FSA. Elections are based on 24 pay periods. The IRS limit is more than $2,500

but COS remains at this limit.

How Does This Benefit Me Visit the ConnectYourCare website or call the CYC/Optum representative during Open Enrollment at 1-913-449-2663.

How to Access Your ConnectYourCare Account as a New Participant: 1) On or after March 1, 2022, visit www.ConnectYourCare.com and click on the “Log In/Sign Up” link.

You must sign up as a “New User Registration” to access your new ConnectYourCare account and set up a new username and password. a. Enter the required sign-up information for accurate identification (last and first name, MM/DD birth date, home zip code and the last four digits of your social security number). b. On the profile page, create a username and password to access your new CYC/Optum account. c. Enter a phone number and e-mail address. d. Read the User Agreement and confirm your acceptance.

2) For reimbursement via bank direct deposit (optional), enter your information in the appropriate boxes on the profile page.

3) Review your contact information on the profile page to ensure your information is correct.

Key Information About the Debit Card: >The debit card is for Unreimbursed Medical FSA expenses only. You cannot use the card for Dependent Care services. >The IRS requires that all card purchases are verified as eligible expenses. >CYC/Optum has automated means to verify many purchases; however, you may be asked to submit verification for some purchases. Always save your receipts.

o >Important: If you do not submit verification of your purchases when requested, your card may be suspended after 90 days

and until the outstanding request has been verified.

o >If you have an e-mail address on file at CYC/Optum, you will receive an e-mail notifying you to take action. If an e-mail is not

on file, a letter will be mailed to your home with instructions. Please always make sure to keep e-mail addresses and home

addresses updated with CYC/Optum.

How to Submit Claims: Beginning March 1, 2022, you can submit claims online at www.ConnectYourCare.com, via fax, scan or mail for expenses incurred between March 1, 2022 and February 28, 2023. CYC/Optum will send out reminders closer to year-end to remind you how much money you have left in your account. However, it is your responsibility to register online to keep track of how many dollars you have outstanding to use. You can also contact ConnectYourCare via phone for account balances. The City no longer process your claims nor keeps track of your balances since this is a voluntary benefit.

Who to Call: Beginning March 1, 2022, you can call the CYC/Optum Customer Service team at 888-339-3685. Customer Service Representatives are available to help you 24 hours a day, 7 days a week.

2022 Annual Benefit Enrollment - January 11th and 12th, 2022

There will NOT be a face-to-face open enrollment venue this year. Date and Time: To speak with a CYC representativeTuesday, January 11, 2022 and Wednesday, January 12, 2022 between 8:00 a.m. and 6:00 p.m. at 1-913-449-2663. <This number is to be used during the two day Open Enrollment only. Otherwise, contact CYC direct at 1-888-339-3685.

Open Enrollment Standard video: FSA Open Enrollment Standard Video Flexible Spending Healthcare Account short video: FSA Healthcare Video Flexible Spending Dependent Daycare Account short video: FSA Dependent Care Video

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Voluntary Term Life and AD&D Insurance | MetLife

Employee Spouse Child(ren)

Coverage Increments $5,000 $5,000 Under 6 months: $100

6 months to Age 26: $10,000

Maximum Benefit Amount $500,000 $100,000 $10,000

Guaranteed Issue Amount (applies to new hires only) $100,000 $30,000 $10,000

Voluntary Term Life/AD&D allows you to purchase additional coverage at your own financial expense to ease your loved ones’ financial burden if something should happen to you. Group discounted rates are available. Make sure your beneficiary information is updated, www.benefitsconnect.net/springfieldil An employee’s maximum benefit election cannot exceed 3x their basic annual earnings. A spouse’s maximum election cannot exceed 50% of what the employee takes out on themselves. Statement of Health required for any additional benefit amount requests. The cost of the benefit is 100% paid for by you. Your age and the amount of insurance you elect determines the premium you’ll pay. Costs will go up as you age.

Basic Life and AD&D Insurance | MetLife

Basic Life Insurance is provided at no cost to you and may help to ease the financial burden on your loved ones should you pass away. Accidental Death and Dismemberment (AD&D) provides an additional benefit to your beneficiary should you suffer loss of life due to a covered accident or suffer the loss of limb, sight, or vision due to a covered accident.

Basic Life/Accidental Death & Dismemberment

Benefit Amount $25,000 per employee - Life

$25,000 per employee - AD&D

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Accident insurance can help to cover costs not covered by your medical plan. See certificate for full benefit details.

Accident Insurance | MetLife

Benefit Type Benefit Amount You’re Paid

Injuries

Second and Third Degree Burns $50 - $5,000

Coma $5,000

Concussion $200

Dislocations $50 - $3,000

Fractures $50 - $3,000

Medical Services and Treatments

Emergency Care $25 - $50

Non Emergency Care $25

Initial Doctor Visit $50

Ambulance $750 (air) or $200 (ground)

Hospital Coverage (Accident)

Standard Hospital Admission $500 - $1,000 per accident

ICU Admission $500 - $1,000 per accident

Hospital Confinement $100 a day

ICU Confinement $200 a day

Other Benefits

Eye Injury $200

Blood/Plasma $300

Laceration $25 - $200

Physical Therapy $15

Health Screening Benefit (Wellness) $60 (payable 1x per calendar year per family member enrolled)

Lodging $100 per night up to 31 nights per calendar year

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Critical Illness Insurance | MetLife

Critical Illness insurance can help safeguard your finances by providing a lump-sum payment when your family needs it most. See certificate for full benefit details.

Eligible Individual Initial Benefit Requirements

Employee $10,000, $20,000, $30,000,

$40,000 or $50,000 Coverage is guaranteed provided you are actively at work.

Spouse 50% of the employee’s

initial benefit Coverage is guaranteed provided the employee is actively at work and the spouse is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.

Dependent Child(ren) 50% of the employee’s

initial benefit Coverage is guaranteed provided the employee is actively at work and the dependent is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.

Covered Condition Initial Benefit Recurring Benefit

Cancer—Full Benefit 100% of Initial Benefit 50% of Initial Benefit

Cancer—Partial Benefit 25% of the Initial Benefit 12.5% of the Initial Benefit

Heart Attack 100% of Initial Benefit 50% of Initial Benefit

Stroke 100% of Initial Benefit 50% of Initial Benefit

Coronary Artery Bypass Graft 100% of Initial Benefit 50% of Initial Benefit

End Stage Renal Failure 100% of Initial Benefit Not applicable

Major Organ Transplant Benefit 100% of Initial Benefit Not applicable

Alzheimer’s Disease 100% of Initial Benefit Not applicable

Covered conditions include but are not limited to:

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Hospital Indemnity Insurance | MetLife

Hospital Indemnity Insurance can complement existing medical coverage and help fill financial gaps caused by out-of-pocket expenses such as deductibles, co-payments, and non-covered medical services. See certificate for full benefit details.

Benefit Type High Plan Benefit

Restrictions Low Plan Benefit

Hospital Coverage (Accident)

Admission $1,000 per accident (non-ICU)

$2,000 per accident (ICU) Must occur 180 days

after the accident. $500 per accident (non-ICU)

$1,000 per accident (ICU)

Confinement $200 per day (non-ICU)

$400 per day (ICU) (for up to 31 days)

Must occur 180 days after the accident.

$100 per day (non-ICU) $200 per day (ICU) (for up to 31 days)

Inpatient Rehab

$200 per day, up to 15 days per accident and 30 days per

calendar year

Must occur immediately following hospital

confinement and occur with 365 days after the

accident.

$100 per day, up to 15 days per accident and 30 days per

calendar year

Hospital Coverage (Sickness)

Admission $1,000 (non-ICU)

$2,000 (ICU)

Payable 1x per calendar year.

$500 (non-ICU) $1,000 (ICU)

Confinement $200 per day (non-ICU)

$400 per day (ICU) (for up to 31 days)

Paid per sickness. $100 per day (non-ICU) $200 per day (ICU) (for up to 31 days)

Other Benefits

Health Screening (Wellness)

$60

Payable 1x per calendar year per family member

enrolled.

$60

Cancer protection provides a financial safety net to assist in a time of need. See certificate for full benefit details.

Eligible Individual Initial Benefit Requirements

Employee $10,000, $20,000, $30,000,

$40,000 or $50,000

Coverage is guaranteed provided you are actively at work.

Spouse 50% of the employee’s

initial benefit

Coverage is guaranteed provided the employee is actively at work and the spouse is not subject to a

medical restriction as set forth on the enrollment form and in the Certificate.

Dependent Child(ren) 50% of the employee’s

initial benefit

Coverage is guaranteed provided the employee is actively at work and the dependent is not subject to a medical

restriction as set forth on the enrollment form and in the Certificate.

Cancer Insurance | MetLife

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Health Screening Benefits | MetLife

With MetLife’s Health Screening Benefits, you are eligible to receive money each calendar year when you or a covered family member have preventive screenings or tests performed. Health Screening Biometrics performed at the Leadwell clinic are eligible for this benefit. :

• $60 for accident insurance • $50 for critical illness insurance • $60 for hospital indemnity insurance • $50 for cancer insurance

For more information, visit www.metlife.com/mybenefits or call 800-438-6388.

Short & Long-Term Disability | UNUM

If you become ill or suffer an injury that prevents you from working, this form of disability insurance replaces a portion of your income for a defined maximum period of time.

Voluntary Short Term Disability: • Coverage pays for up to 60% of your income to a maximum of $5,000 per month in benefits. • Fixed rate and true portability (you own the policy and can take it with you if you ever leave City of

Springfield. Voluntary Long-Term Disability:

• Coverage pays for up to 60% of your gross monthly earnings up to $5,000 if you become ill or injured and can’t work for an extended period of time.

• Includes Worldwide Travel Assist designed to help you when an unexpected emergency occurs. Service is available to you and your family members 24 hours a day, 365 days a year.

• Includes Work-Life Balance EAP program designed to provide access to professional assistance for a wide range of work related issues.

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Employee Premium Information

Employee Medical Premiums*

Employee Dental Premiums* Basic Dental Enhanced Dental

Employee Only $15.00 $25.14

Employee + 1 $30.02 $50.37

Family $45.74 $76.69

Military (Adult Child Age 26-30) $15.00 $25.14

Employee Vision Premiums* Vision

Employee Only $2.70

Employee + 1 $4.71

Family $7.52

Military (Adult Child Age 26-30) $2.70

Monthly COBRA Medical Premiums

Point of Service (POS) High Deductible Health Plan (HDHP)

Wellness w/o Wellness Wellness w/o Wellness

Employee Only $87.88 $96.67 $0.00 $0.00

Family $201.97 $222.17 $143.02 $157.33

Military (Adult Child Age 26-30) $288.11 $233.96

* Health, Dental and Vision premiums will automatically be applied to Section 125 (Premium Only Plans). Premium amounts through Section 125 cannot be revoked (dropped) after the start of the plan year or until the next enrollment or a life changing event.

Dental and Vision rates remain the current rates when electing COBRA. COBRA rates are subject to change based on the changes in the entire plan on a quarterly review. COBRA rates are based on the recommendation of an outside actuarial projection. COBRA rates reflect the entire cost of the health program and a 2% administrative fee. Participant coverage is individual and any participant has the right to cancel the beginning of any month. Coverage is up to the maximum described to you by the plan sponsor.

Point of Service (POS) High Deductible Health Plan (HDHP)

Employee Only $1,060.32 $707.60

Employee + 1 $2,160.91 $1,439.33

Family $2,931.66 $1,951.75

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Retiree Premium Information

Retiree Dental Premiums* Basic Dental Enhanced Dental

Employee Only $30.00 $50.28

Employee + 1 $60.03 $100.73

Family $91.47 $153.37

Military (Adult Child Age 26-30) $30.00 $50.28

Retiree Medical Premiums*

Point of Service (POS) High Deductible Health Plan (HDHP)

Employee Only $468.30 $281.57

Employee + 1 $944.64 $613.10

Family $674.99 $1,008.84

Military (Adult Child Age 26-30) $468.30 $281.57

Retiree Vision Premiums* Vision

Employee Only $5.39

Employee + 1 $9.41

Family $15.04

Military (Adult Child Age 26-30) $5.39

* Health, Dental and Vision premiums will automatically be applied to Section 125 (Premium Only Plans). Premium amounts through Section 125 cannot be revoked (dropped) after the start of the plan year or until the next enrollment or a life changing event.

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Voluntary Life Premiums

Employee or Spouse Age Monthly Cost*

(per $1,000 of coverage)

<30 $0.050

30-34 $0.060

35-39 $0.084

40-44 $0.100

45-49 $0.150

50-54 $0.230

55-59 $0.430

60-64 $0.660

65-69 $1.270

70+ $2.060

Child(ren) $0.144 per $1,000 of coverage

Voluntary AD&D Premiums

Monthly Cost

(per $1,000 of coverage)

Employee $0.029

Employee & Family $0.037

Use the table below to calculate your premium based on the amount of life insurance you will need. Example: $100,000 Supplemental Life Coverage

Repeat the three easy steps above to determine the cost for each coverage selected.

1. Enter the rate from the table (example age 36)

$0.090 $__________________________

2. Enter the amount of insurance in thousands of dollars (example: for $100,000 of coverage enter $100)

$100 $__________________________

3. Monthly premium (1) x (2) $9.00 $__________________________

36

Monthly Rates

Employee $5.09

Employee + Spouse $9.56

Employee + Child(ren) $11.05

Employee + Family $13.60

Accident Insurance Premiums

Critical Illness Premiums

Monthly Rates per $1,000 of Coverage

Age Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

<25 $0.17 $0.30 $0.32 $0.45

25-29 $0.19 $0.32 $0.33 $0.47

30-34 $0.26 $0.42 $0.41 $0.57

35-39 $0.38 $0.59 $0.53 $0.74

40-44 $0.58 $0.87 $0.73 $1.02

45-49 $0.90 $1.31 $1.05 $1.46

50-54 $1.36 $1.93 $1.51 $2.08

55-59 $1.97 $2.74 $2.12 $2.89

60-64 $2.88 $3.96 $3.03 $4.11

65-69 $4.41 $5.98 $4.55 $6.13

70+ $6.51 $8.92 $6.66 $9.07

High Plan Low Plan

Employee $22.62 $12.26

Employee + Spouse $44.43 $24.07

Employee + Child(ren) $40.94 $22.18

Employee + Family $69.65 $37.74

Hospital Indemnity Premiums

37

Cancer Insurance Premiums

Monthly Rates per $1,000 of Coverage (Tobacco Users)

Age Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

<25 $0.26 $0.45 $0.40 $0.59

25-29 $0.26 $0.45 $0.40 $0.59

30-34 $0.35 $0.58 $0.49 $0.71

35-39 $0.49 $0.79 $0.62 $0.92

40-44 $0.78 $1.20 $0.92 $1.34

45-49 $1.17 $1.73 $1.30 $1.87

50-54 $1.67 $2.41 $1.80 $2.54

55-59 $2.21 $3.12 $2.34 $3.26

60-64 $2.73 $3.80 $2.86 $3.94

65-69 $2.93 $4.08 $3.07 $4.22

70+ $2.95 $4.10 $3.09 $4.24

Monthly Rates per $1,000 of Coverage (Non-Tobacco Users)

Age Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

<25 $0.17 $0.30 $0.30 $0.43

25-29 $0.17 $0.30 $0.30 $0.43

30-34 $0.21 $0.36 $0.35 $0.50

35-39 $0.29 $0.47 $0.42 $0.61

40-44 $0.44 $0.69 $0.58 $0.82

45-49 $0.64 $0.96 $0.77 $1.10

50-54 $0.90 $1.31 $1.03 $1.44

55-59 $1.17 $1.67 $1.31 $1.81

60-64 $1.43 $2.01 $1.57 $2.15

65-69 $1.52 $2.13 $1.65 $2.27

70+ $1.52 $2.13 $1.66 $2.27

38

Benefit Resources & Contact Information

Benefits Contact Information

Contact Benefits Department

Email Address humanresources@springfield.il.us

Phone Number 217-789-2446

Leadwell Clinic

Carrier Leadwell

Website for Wellness http://www.hshsmedicalgroup.org/wellsource

Phone Number 217-993-0998

Elixir Pharmacy Services

Carrier Elixir Pharmacy Services

Website www.elixirsolutions.com

Phone Number 800-771-4648

Vision

Carrier UniCare

Website www.unicare.com

Phone Number 888-884-8428

Network UniView Vision

Voluntary Life and AD&D Insurance

Carrier MetLife

Website www.metlife.com

Phone Number 800-438-6388

Short-Term and Long-Term Disability Insurance

Carrier UNUM

Website www.unum.com

Phone Number 866-679-3054

Dental PPO

Carrier MetLife

Website www.metlife.com

Phone Number 800-942-0854

Network/Group PDP Plus / Group #212942

Flexible Spending Account

Carrier ConnectYourCare/Optum

Website www.connectyourcare.com

Phone Number 888-339-3685

Cancer/Critical Illness/Accident/ Hospital Indemnity Insurance

Carrier MetLife

Website www.metlife.com

Phone Number 800-438-6388

Medical — Claims

Carrier Trustmark Health Benefits

Website www.MyTrustmarkBenefits.com

Phone Number 800-848-3012

Medical — Network

Carrier HealthLink

Website www.healthlink.com

Phone Number 800-624-2356

39

300 S. 7th Street, Room B-4 Phone: (217) 789-2346 Fax: (217) 789-2190

www.scecu.org

Open enrollment for the $16.00 IMRF endorsed term life insurance will be Monday, January 4, 2022 through Wednesday January 12, 2022. Deductions are only withheld from the first check of the month and would begin in March, 2022 (with coverage effective April 1, 2022; first of the month following your first payroll deduction). Informational BROCHURE and ENROLLMENT FORM can be found on this link https://ncpers.memberbenefits.com/forms/ There is an informational video on this link https://vimeo.com/355180269 Just type each link in a Google browser for viewing. Brochure –click on Group Life Insurance Plan Brochure; then select NCPERS $16.00 (IMRF). Enrollment form – click on Employee Enrollment Form NCPERS $16.00 Plan; print, complete and turn into the City Office of Human Resources. The last day enrollment forms will be accepted is Wednesday January 12, 2022. Enrollment forms should be scanned to (sara.taylor@springfield.il.us), or faxed to 217.789.2118, or dropped off at the MCW building, 1st floor in the secured blue metal HR drop box between the security booth and the elevators by the deadline – no exceptions. Exclude your date of birth and social security number (HR will add that information). If you presently are enrolled and wish to cancel your coverage, you may do so at any time. An e-mail request to cancel is required to sara.taylor@springfield.il.us and deductions would cease on your first paycheck of the following month. If currently enrolled in any of the NCPERS plans, you do not have to re-enroll and coverage continues. Sworn Police and Fire are not eligible for this benefit.

If you have any questions, please contact Sara Taylor via email at sara.taylor@springfield.il.us or phone 217.789.2446 ext. 6126. Thank you.

Brief chart description below. Full plan details visit https://ncpers.memberbenefits.com/forms/ and click on Group Life Insurance Plan Brochure.

A group rate that’s competitive

NCPERS guarantees that every active member, regardless of age, pays $16 a month, and it will never increase. Dependent Group Members Decreasing Term Life

Member’s Age at Time

of Claim

Group Decreasing Term Life

Group AD&D

Total Benefit for Accidental

Death

Spouse/Domestic Partner

Child(ren)-

Less than 25 $225,000 $100,000 $325,000 $20,000 $4,000

25 to 29 $170.000 $100,000 $270,000 $20,000 $4,000

30 to 39 $100,000 $100,000 $200,000 $20,000 $4,000

40 to 44 $65,000 $100,000 $165,000 $18,000 $4,000

45 to 49 $40,000 $100,000 $140,000 $15,000 $4,000

50 to 54 $30,000 $100,000 $130,000 $10,000 $4,000

55 to 59 $18,000 $100,000 $118,000 $7,000 $4,000

60 to 64 $12,000 $100,000 $112,000 $5,000 $4,000

65 and over $7,500 $7,500 $15,000 $4,000 $4,000 Payment Examples:

1. If an insured member age 38 dies of natural causes, the beneficiary would receive $100,000. If death is due to a covered accident,

$200,000 would be payable.

2. If the spouse or domestic partner of a 42-year-old member dies, the member would receive $18,000.

3. If a dependent child less than 26 dies, the payment to the member would be $4,000.

*Unmarried children up to age 26 are covered, including adopted children, stepchildren, and foster children who depend on you for support.

Dependents in the military service are not eligible.

Please note: insurance coverage for a child will not end at age 26 if the child is then mentally or physically incapable of earning a living and

meet the definition of Qualified Dependent.

IMRF Active Members Only

Sworn Police and Fire are not eligible for this benefit

1 -800-525-8056

41

2022 Annual Notices City of Springfield

HIPAA Special Enrollment Notice

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 31 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 for a dependent spouse within 31 days after the marriage. You must request enrollment for a dependent child within 60 days immediately following the birth, adoption, or placement for adoption. Finally, you and/or your dependents may have special enrollment rights if coverage is lost under Medicaid or a State health insurance (“SCHIP”) program, or when you and/or your dependents gain eligibility for state premium assistance. You have 60 days from the occurrence of one of these events to notify the company and enroll in the plan. To request special enrollment or obtain more information, contact City of Springfield Benefits—Office of Human Resources.

Women’s Health and 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. . All stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a 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 Trustmark.

Newborns and Mothers’ Health Protection Act (NMHPA)

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).

Genetic Information Nondiscrimination Act (GINA)

The Genetic Information Nondiscrimination Act (GINA) prohibits health benefit plans from discriminating on the basis of genetic information in regards to eligibility, premiums, and contributions. This generally also means that private employers with more than 15 employees, its health plan, or “business associate” of the employer, cannot collect or use genetic information (including family medical history information). The one exemption would be that a minimum about of genetic testing results may be used to make a determination regarding a claim. You should know that GINA is treated as protected health information (PHI) under HIPAA. The plan must provide that an em-ployer cannot request or require that you reveal whether or not you have had genetic testing; nor can you employer require you do participate in a genetic test. An employer cannot use any genetic information to set contribution rates or premiums.

COBRA Continuation of Coverage Notice

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. For additional information regarding COBRA qualifying events, how coverage is provided, and actions required to participate in COBRA coverage, please contact City of Springfield Benefits—Office of Human Resources.

42

USERRA Notice

The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) established requirements that employers must meet for certain employees who are involved in the uniformed services. In addition to the rights that you have under COBRA, you (the employee) are entitled under USERRA to continue the coverage that you (and your covered dependents, if any) had under the City Of Springfield Plan. You Have Rights Under Both COBRA and USERRA. Your rights under COBRA and USERRA are similar but not identical. Any election that you make pursuant to COBRA will also be an election under USERRA, and COBRA and USERRA will both apply with respect to the continuation coverage elected. If COBRA and USERRA give you different rights or protections, the law that provides the greater benefit will apply. The administrative policies and procedures described in the attached COBRA Election Notice also apply to USERRA coverage, unless compliance with the procedures is precluded by military necessity or is otherwise impossible or unreasonable under the circumstances. Definitions “Uniformed services” means the Armed Forces, the Army National Guard, and the Air National Guard when an individual is engaged in active duty for training, inactive duty training, or full-time National Guard duty (i.e., pursuant to orders issued under federal law), the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency. “Service in the uniformed services” or “service” means the performance of duty on a voluntary or involuntary basis in the uniformed services under competent authority, including active duty, active and inactive duty for training, National Guard duty under federal statute, a period for which a person is absent from employment for an examination to determine his or her fitness to perform any of these duties, and a period for which a person is absent from employment to perform certain funeral honors duty. It also includes certain service by intermittent disaster response appointees of the National Disaster Medical System. Duration of USERRA Coverage General Rule: 24-Month Maximum. When a covered employee takes a leave for service in the uniformed services, USERRA coverage for the employee (and covered dependents for whom coverage is elected) can continue until up to 24 months from the date on which the employee's leave for uniformed service began. However, USERRA coverage will end earlier if one of the following events takes place:

• A premium payment is not made within the required time;

• You fail to return to work or to apply for reemployment within the time required under USERRA (see below) following the completion of your service in the uniformed services;

• You lose your rights under USERRA as a result of a dishonorable discharge or other conduct specified in USERRA. USERRA and Health FSAs USERRA's continuation coverage requirements for health plans apply to health FSAs. USERRA has no special rules for health FSAs. For example, the limited COBRA obligation for certain health FSAs (as described in the attached COBRA Election Notice) does not apply under USERRA— under USERRA, the right to continuation coverage generally lasts for up to 24 months (unless one of the events described above takes place). COBRA and USERRA Coverage Are Concurrent This means that COBRA coverage and USERRA coverage begin at the same time. However, COBRA coverage can continue for up to 18 months (it may continue for a longer period and is subject to early termination, as described in the attached COBRA Election Notice). In contrast, USERRA coverage can continue for up to 24 months. Premium Payments for USERRA Continuation Coverage If you elect to continue your health coverage pursuant to USERRA, you will be required to pay 102% of the full premium for the coverage elected (the same rate as COBRA), at the times and using the procedures specified in the attached COBRA Election Notice. However, if your uniformed service period is less than 31 days, you are not required to pay more than the amount that you pay as an active employee for that coverage. For the full USERRA notice of rights, which includes details regarding periods of uniformed service as it relates to report-to-work requirements, please contact City of Springfield Benefits—Office of Human Resources.

2022 Annual Notices City of Springfield

43

For More Information About your Options Under Medical 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).

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with City of Springfield 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. City of Springfield has determined that the prescription drug coverage offered by Elixir 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.

Prescription Coverage and Medicare

2022 Annual Notices City of Springfield

44

HIPAA Privacy Notice: Your Information. Your Rights. Our Responsibilities.

This 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. Your Rights

You have the right to:

• Get a copy of your health and claims records

• Correct your health and claims records

• Request confidential communication

• Ask us to limit the information we share

• Get a list of those with whom we’ve shared your information

• Get a copy of this privacy notice

• Choose someone to act for you

• File a complaint if you believe your privacy rights have been violated Your Choices

You have some choices in the way that we use and share information as we:

• Answer coverage questions from your family and friends

• Provide disaster relief

• Market our services and sell your information Our Uses and Disclosures

• We may use and share your information as we:

• Help manage the health care treatment you receive

• Run our organization

• Pay for your health services

• Administer your health plan

• Help with public health and safety issues

• Do research

• Comply with the law

• Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• Address workers’ compensation, law enforcement, and other government requests

• Respond to lawsuits and legal actions Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care. Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

2022 Annual Notices City of Springfield

45

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint. Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care

• Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways: Help manage the health care treatment you receive

• We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you. Pay for your health services

• We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan

• We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Your Information. Your Rights. Our Responsibilities — Continued

2022 Annual Notices City of Springfield

46

Your Information. Your Rights. Our Responsibilities — Continued

Do research

• We can use or share your information for health research Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you. Other Instructions for Notice

Effective Date of this Notice—March 1, 2022

2022 Annual Notices City of Springfield

NOTE: This Benefits Summary is merely intended to provide a brief overview of the Company’s employee benefit programs. Employees should review the Company’s employee handbook and actual plan documents for the precise terms of such programs. In the event of any inconsistency between this Benefits Summary and such governing documents, the governing documents will control. The Company reserves the sole and absolute discretion and right to interpret, apply, amend, discontinue or terminate, without prior notice, any and all of the benefit programs referenced herein. Voluntary plans are individual policies and are not considered sponsored or endorsed plans by your employer. See a benefit counselor for your customized quote for any additional benefit programs.