Employee Options Guide

Get registered at www.myUHC.com

Upon enrolling in a State of Nebraska health plan, you will receive a welcome kit from UnitedHealthcare. Go online at www.myUHC.com and register. Once you register, click on “Pharmacies and Prescriptions” and you will be able to:

1. View the most current prescription drug list (also referred to as a formulary).
2. Locate a network pharmacy.
3. Compare drug prices and lower cost options.
4. Find your cost before you go to the pharmacy.
5. Refill and track your mail order prescriptions.
6. View medication limits including quantity limits, prior authorization, and step therapy
7. View drugs not covered under your plan.

Diabetic Supplies

Diabetic supplies covered under the prescription drug benefit include syringes, needles, lancets, blood monitor kits, test strips, blood glucose calibration solutions, urine tests, and blood test strips. Continuous blood glucose monitors and insulin pumps are covered under the medical benefit as Durable Medical Equipment (sensors are covered under both, Medical and Rx). If you have any questions, call customer service at 877-263-0911.

WellNebraska and Regular Health Plans Pharmacy Out-Of-Pocket Maximums

The pharmacy out-of-pocket maximum limits are in addition to the medical out-of-pocket maximums HERE. Once the out-of-pocket maximum has been met for pharmacy co-pays, all prescriptions covered under the plan will be paid 100% by the plan.

Pay the Difference

If a lower cost generic equivalent is available and you choose brand name drug, you will pay the difference in cost between the generic cost and brand name cost, in addition to the appropriate copay. This penalty does not apply if physician does not allow substitution.

Consumer Focused Health Plan

1. If your medication is on the UHC Preventive Drug List, you pay the copay. Your copay will apply towards your annual out-of-pocket maximum. After your limit is met, the plan pays 100% of your costs. For more details, go to das.nebraska.gov/personnel/wellness.
2. For all other covered prescriptions, the full cost of the prescription is applied towards your deductible. Once you meet your deductible, then you pay 20% coinsurance until your annual out-of-pocket limit is met. Then all costs are paid 100% by the plan.

Mail Order – Save money & time!

For medications you take on a regular basis, you can fill a 90-day supply through the OptumRx™ Mail Service Pharmacy. Mail order offers the convenience of home delivery and saves you money. You will also be able to get a 90 day prescription from your local pharmacy.

To start using mail order:

1. Tell your physician you would like to start mail service. Once you and your physician are confident you will continue taking a medication on an ongoing basis, have your physician write a prescription for a 90-day supply, plus up to three refills. Prescriptions with more than three refills will not be processed as it will exceed a one-year maximum supply as required by law.

-OR-

2. Contact OptumRx™ at 800-562-6223, 24 hours a day, seven days a week, and have your prescription label available when you call. You can mail the order form - include with the original prescription(s). Write the member ID and date of birth on each prescription and mail with completed order form. Please fill out one order form per member. You can download an order form from das.nebraska.gov/personnel/wellness.

Your Prescription Medication Options

Your PDL is a list of commonly prescribed medications and their cost levels or tiers, which define the amount you pay for each medication under your benefit. Tier placements on the PDL are reviewed and may change throughout the year. For a current list of your PDL, contact OptumRx at 877-263-0911 or visit www.myUHC.com.

Specialty Pharmacy Program

Optum Specialty Pharmacy

Certain prescriptions on our prescription drug listing require that you use the Optum Specialty Pharmacy to fill your prescriptions. Specialty pharmacies have experience in storing, handling, and distributing these unique medications and typically provide a higher level of customized care for specialty medications than traditional retail pharmacies. Specialty pharmacists and nurses also have additional clinical expertise surrounding these medications and complex diseases.

What is a specialty medication?

An injectable, oral, or inhaled medication is most often considered specialty medication if it:

• Is used to treat a chronic or complex condition
• Requires extra, on-going clinical oversight and additional education for best management
• Has unique storage or shipping requirements
• Is not typically available at retail pharmacies

Contact the Optum Specialty Pharmacy at 855-242-2241 and speak with a Patient Care Coordinator to help set up your account, order refills, and answer questions about your prescription.

Are YOU getting the most out of your Pharmacy Benefit?

• Register at www.myUHC.com
• Choose drugs on Tier 1, when available
• Use mail order

Vision Benefits

Benefits are provided by EyeMed Vision Care

State of Nebraska teammates who elect vision benefits will enjoy the advantage of America’s largest vision care network, comprised of independent providers and top optical retailers. This means you get access to more convenient evening and weekend hours to fit anyone’s schedule.

Teammates can choose from two vision plans – Basic or Premium. All premiums are paid through pre-tax, payroll deductions. New participants will receive an insurance ID card from EyeMed upon enrollment however an ID card is not needed to obtain benefits.

Accessing your vision care benefit is easy:

• Find a provider near you by logging in to EyeMed.com and selecting the Insight Network to schedule an appointment with a simple phone call or stop by one of the many retail providers who offer walk-in appointments.
• When out on the EyeMed portal or if you are in the EyeMed app, make sure to check out the special offers tab to see if any of the value-added benefits listed could boost your current vision benefits with additional savings.

NOTE: Vision benefits are available once every Plan Year.

2023 - 2024 Plan Year

Just as a reminder, Insight Network is the network you choose when searching for an in-network provider.

Click here to view the Vision Plan Premiums

LEGAL DISCLAIMER: Member will receive a 20% discount on items not covered by the plan at network Providers, which may not be combined with any other dis-counts or promotional offers, and the discount does not apply to EyeMed Provider’s professional services or contact lenses. Retail prices may vary by location. Allowances are one-time use benefits, no remaining balance. Members also receive a 40% discount off complete pair eyeglass purchases and a 15% discount off conventional contact lenses once the funded benefit has been used. The plan design is offered with the EyeMed Access panel of providers. Limitations and exclusions apply. Insured plans are underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New York. Fidelity Security Life ºPolicy Number VC-19/VC-20 form number M-9083.

Dental Benefits

Benefits are provided by Ameritas

The State of Nebraska offers dental insurance to all full-time and part-time teammates. All of the premiums are paid by the teammate and collected through pre-tax payroll deductions. For new plan participants, dental ID cards will be mailed to your home.

Our dental program promotes routine dental care as part of our wellness culture for you and your family. Whether or not you elect health coverage, you can choose dental coverage for yourself and your eligible dependents. The dental plan is a participating provider organization (PPO) with a network of participating providers. You have the option of selecting dental care in- or out-of-network each time you receive dental care, but the plan pays the greatest benefit for care received from a provider in the Ameritas network.

Dental Rewards®

Dental Rewards® is a program offered by Ameritas and encourages good dental habits through regular dental checkups. It is available to all family members who participate on the dental plan. If you file at least one dental claim during the plan year and total benefits paid are less than $500, your annual maximum for the following year will be increased by $250 ($350 if using a network dentist). This continues until you reach a total reward of $1,000. The Dental Rewards amount is available to use in future years in addition to your annual maximum. It can only be reduced if you have claims totaling more than $1,000 or if you fail to submit at least one claim during any given year.

NOTE: Orthodontia and TMJ procedures are excluded from Dental Rewards as they have their own maximum benefit.

Penalty for Late Entrants

A late entrant is any participant on the plan who does not elect coverage during your initial 30 days of eligibility or any participant who re-enrolls in the dental plan after dropping coverage. It applies to both you and your dependents.

As late entrants, your benefits will be limited to only preventive procedures for the first 12 months that you are covered. After 12 months, you will have access to all of the plan’s benefits.

Click here to view the Dental Plan Premiums

Find a Participating Provider

Visit our website at https://explore.ameritas.com/nebraska/ and select Classic (PPO) Plus Network Option or call 800-487-5553.

Type 1 – Preventive Procedures

Exam & cleanings (two per year, does not have to be at exactly six-month intervals), x-rays, sealants.

Type 2 – Basic Procedures

Fillings, root canals, gum disease treatment, extractions.

Type 3 – Major Procedures

Initial and replacement crowns, dentures, bridges.

** Premium Plan ONLY

Type 1 and 2 procedures for out-of-network providers will be reimbursed on an incentive basis that progressively increases each plan year. New plan members begin at 50% coinsurance. As long as plan members visit the dentist and have at least one covered procedure performed each plan year, they advance one co-insurance level the following plan year until they reach 70%. If a plan member fails to have at least one dental procedure performed during any benefit year, he or she will revert back to the beginning coinsurance level to begin advanc-ing through the levels.

Short-Term Disability Benefits

Benefits are offered through UnitedHealthcare

Please note: Your benefit payment will be reduced by other income you receive or are eligible to receive, due to your disability. This includes, but is not limited to, sick leave or donated leave. (Please see the Certificate of Coverage for additional details)

How the plan works

The Short-term Disability plan will pay you 60% of your paycheck each week if you have a qualifying disability on the 1st day of injury or the 8th day of a sickness and you are unable to perform your job duties for up to a maximum of 26 weeks.

This means you will have a weekly income to help you and your family pay for expenses like your mortgage or rent, medical bills, food and more.

You can even work part-time

Being productive feels good. That’s why the plan also allows you to work part-time and still receive benefit payments. We understand that you may have to work your way back up to earning 100 percent of your income, which is the goal.

Disability specialists can help you return to work

The plan includes personal support from disability specialists who will work with you and your employer to help you return to work more quickly so you can get back to work safely and back to earning your full wage. Due to the complex nature of disability claims, it is not possible to provide answers to questions related to hypothetical claims.

Premium Calculation

1. Enter your Basic Gross Annual Salary up to $150,000 pay (not including overtime)
2. Annual salary divided by 52 weeks (#1 / 52)
3. Benefit % = 60%
4. Multiply by Benefit % (#2 X 0.60)
5. Weekly Benefit divided by 10 (#4 / 10)
6. Enter the rate for your age as of July 1st (see rate table below)
7. Your monthly cost is (#5 X #6)

Why UnitedHealthcare Short-term Disability?

• Income protection with weekly payments
• Personal claim support to help you through the process
• Disability specialists to help you get back to work safely

Pre-existing Conditions Exclusion

UnitedHealthcare will not cover any disability that begins during the first 12 months after the covered person’s effective date of insurance that is caused or contributed to by a pre-existing condition.

Pre-existing condition means: any Sickness or Injury including Mental Illness, Substance Abuse or Subjective Symptoms for which the Covered Person, within 3 months prior to his Effective Date of insurance:

• was diagnosed by or received Treatment from a legally qualified Physician; or
• had symptoms for which an ordinarily prudent person would have sought Treatment.

If you enroll when you first become eligible, you don’t need to provide evidence of insurability, which requires you to complete a form to prove your physical condition.

UnitedHealthcare Disability products are provided by UnitedHealthcare Insurance Company. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, see your Certificate of Coverage or contact your employer. UnitedHealthcare Insurance Company is located in Hartford, CT.

Long-Term Disability Benefits

Benefits are offered through UnitedHealthcare

Almost half of American adults indicate they can’t pay an unexpected $400 bill without having to take out a loan or sell something to do so.
Disability Statistics; Chance of Becoming Disabled.” Council for Disability Awareness: Prevention, Financial Planning, Resources and Information, 28 Mar. 2018, disabilitycanhappen.org/disability-statistic/

Please note: Your benefit payment will be reduced by other income you receive or are eligible to receive, due to your disability. This includes, but is not limited to, sick leave or donated leave. (Please see the Certificate of Coverage for additional details)

Help secure a monthly income if an illness or injury keeps you out of work for a long period of time.

Don’t let an off-the-job accident or an illness leave you in a financial bind if you are unable to work for months.

An injury or long illness can create more than just financial and emotional stress. That’s why a UnitedHealthcare Long-term Disability plan is designed to do two important things:

1. Give you long-term financial support.
2. Help reduce stress and health issues that can prolong being out of work.

How the plan works

The Long-term Disability plan will pay you 60% of your paycheck each month if you have a qualifying long-term disability where you are unable to perform your job duties for 180 days or longer.

A steady monthly income not only helps you and your family cover expenses, it may help reduce stress that comes with being out of work for a long period.

You can even work part-time

Being productive feels good. That’s why the plan also allows you to work part-time and still receive benefit payments. We understand that you may have to work your way back up to earning 100 percent of your income, which is the goal.

Your well-being is what matters most

The plan includes resources and benefits designed to support you along the way and at no extra cost:

• 24/7 Employee Assistance Program (EAP)
• Return-to-work preparation
• Workplace modification benefit

Premium Calculation

1. Enter your Basic Gross Annual Salary up to $150,000 pay (not including overtime)
2. Annual salary divided by 12 = covered monthly earnings
3. Monthly divided by 100 (#2 / 100)
4. Enter the rate for your age as of July 1st
5. Your monthly cost (#3 X #4)
6. Monthly Benefits = 60% of Covered Monthly earnings (#2 X 0.60)

* Benefits reduced. Check website for further information.

Why UnitedHealthcare Long-term Disability?

• Income protection with monthly payments
• Personal claim support to help you through the process
• 24/7 Employee Assistance Program for confidential and emotional support
• Disability specialists to help you adjust and get back to work safely

Pre-existing Conditions Exclusion

UnitedHealthcare will not cover any disability that begins during the first 12 months after the covered person’s effective date of insurance that is caused or contributed to by a pre-existing condition.

Pre-existing condition means: any Sickness or Injury including Mental Illness, Substance Abuse or Subjective Symptoms for which the Covered Person, within 3 months prior to the Effective Date of insurance:

• was diagnosed by or received Treatment from a legally qualified Physician; or
• had symptoms for which an ordinarily prudent person would have sought Treatment.

If you enroll when you first become eligible, you don’t need to provide evidence of insurability, which requires you to complete a form to prove your physical condition.

Life and AD&D Insurance Benefits

Benefits are provided by The Hartford

The State of Nebraska offers both life and accidental death and dismemberment (AD&D) insurance coverage to teammates. Newly hired teammates may elect any supplemental coverage amount within the first 30 days of employment without having to provide evidence of insurability.

Basic Life Insurance

The state provides eligible full-time teammates with a basic life insurance benefit of $20,000 at no cost. Part-time teammates, at or greater than 20 hours per week, are eligible for the $20,000 insurance benefit and pay 50% of the monthly rate. The part-time rate is $0.48 per month.

Supplemental Life Insurance – Dependent *

You may also purchase optional life insurance for your spouse and dependent child(ren) up to age 26. There are two dependent life options to choose from and both include coverage for spouse and your child(ren) but vary by spouse’s age.

NOTE: If both spouses are employed by the state, only one may cover the children on the state’s supplemental dependent life coverage. Also, they cannot elect dependent life coverage on each other.

* You must be enrolled in Basic Life to elect Supplemental Life Insurance - Dependent.

Accidental Death & Dismemberment Insurance (AD&D) – Teammate Only *

AD&D insurance pays benefits if you die or suffer certain serious injuries as a result of an accident. The AD&D benefit is paid based upon the type of loss you suffer.

* You must be enrolled in Basic Life to elect AD&D Life Insurance.

Accelerated Death Benefit

The voluntary group life insurance plan offers an “Accelerated Death Benefit” that allows you to receive a partial life insurance benefit if you are:

• Diagnosed with a terminal illness and not expected to survive more than 24 months; or

The Amount of Accelerated Death Benefit

You can request up to the Accelerated Death Benefit percentage or 80% of the life insurance that is currently in effect, however, not:

• Less than $3,000 or
• More than $500,000

Requesting an Accelerated Death Benefit

To request the Accelerated Death Benefit, you must complete and submit a request form to The Hartford. The request form must include:

• A statement of the amount requested; and
• A physician’s statement verifying that you are suffering from a non-correctable terminal illness or are suffering from one of the listed medical conditions that is expected to result in a drastically limited life span. The statement must also provide the following information:
• All medical test results;
• Laboratory reports; and
• All supporting documentation and information on which the physician’s statement is based.

Your human resource partner will be able to assist with the completion/submission of the “Accelerated Death Benefit” claim form.

Supplemental Employee Life Insurance *

You may elect to purchase additional life insurance coverage for yourself. Coverage can be purchased in increments of 0.5, 1, 1.5, 2, 3, 4, or 5 times your annual salary. Amounts will be rounded to the next highest $1,000. Teammates pay the entire cost for supplemental life insurance through a payroll deduction. Employee supplemental life rates are based on your age and salary as of July 1 of each year.

During Open Enrollment, teammates currently enrolled in Supplemental Life may increase one increment of coverage without approval by the carrier. Any increases outside of the Open Enrollment period, or any increases greater than one increment, will require evidence of insurability and approval by the carrier.

* You must be enrolled in Basic Life to elect Supplemental Life Insurance.

Open Enrollment Only

If you are currently enrolled in supplemental life insurance coverage, you may increase your coverage level by one increment without providing evidence of insurability.

Calculating Employee Life Insurance

Your cost for coverage is based on the increment you choose, your age, and your salary. Follow the simple steps below to determine your exact monthly cost.

Monthly Cost Calculation Example

1. Callie is 54 years old and makes $20.949/hour. She works a 40-hour week, or 2080 hours a year. This makes her annual basic gross pay $43,573.92.
2. She elects 4 times her salary, so she multiplies her annual basic gross pay, $43,573.92, by 4 to get $174,295.68.
3. Then, she rounds up to the next highest $1,000, which is $175,000 in supplemental life coverage.
4. The rate per $1,000 of coverage for someone Callie’s age is $0.142. She multiples $175,000 by $0.142 for a total of $24,850.
5. Finally, she divides by $24,850 by 1,000. Callie’s cost of supplemental life coverage will be $24.85 each month.

Employee Assistance Program (EAP) *

Benefits are offered through Deer Oaks Employee Assistance Program

The Deer Oaks Employee Assistance Program (EAP) is a free service provided for teammates and their household members by the State of Nebraska. The EAP is designed to help you and your family manage life’s challenges.

Through this program, you and your family members may access a wide variety of counseling, referral, and consultation services to help you deal with personal and work-related issues that may be affecting your job performance or personal well-being. Whether you seek mental health counseling, work and life consultation services, legal and financial resources, assistance with locating child and elder care facilities, or you have uncertainty about retirement, Deer Oaks is there to assist with these and other requests, 24 hours per day, 7 days per week.

Deer Oaks offers a multidisciplinary team of professional counselors and work/life consultants trained to assist with such issues as:

• Work/Life Balance
• Depression/Anxiety
• Substance Abuse
• Preparing for Retirement
• Emotional & Psychological Issues
• Life Changes & Transitions
• Stress & Time Management
• Legal & Financial Difficulties
• Family & Marital Problems
• Child/Elder/Adult Care Issues
• Healthy Lifestyles
• Loss & Grief

These services are completely confidential and may be easily accessed 24/7 by calling the toll-free Helpline at 866-792-3616. You may also visit us online at www.deeroakseap.com (login and password are “SON”) to browse articles, interactive assessments, audio and video files, and to participate in monthly webinars and live chat sessions.

Check out the iConnectYou Mobile App through which members may engage with their benefit via phone, video, or instant messaging. The app not only allows users to initiate contact with the program, but can also be used to deliver structured telephone or video counseling. Informational resources are also available. iConnectYou is available as a free download via Google Play and App Store.

* For participating agencies only.

Program Access

• Helpline: (866) 792-3616
• Website: www.deeroakseap.com
• Login and Password: SON

FEATURES INCLUDE:

• Regularly updated information and links
• Downloadable articles and tip sheets
• Self-search provider databases for summer camps, education resources, pet sitters, attorneys, financial advisors, volunteer opportunities, and more
• Legal and medical encyclopedias
• Financial and daily living calculators
• Savings Center providing 25 to 70 percent discounts on name brand merchandise
• Spanish-language content

Termination/Retirement/COBRA

Upon leaving employment with the State of Nebraska, it is important for you to know the following information about your benefits.

Address & Phone Number Changes

Please keep the State of Nebraska informed of any changes to your address and/or phone number. The State of Nebraska needs this information in order to send you a W-2 and 1095-C in January following the year in which you terminate or retire.

Medical, Dental and Vision

Medical, dental, and/or vision coverage ends on the last day of the month in which you terminate. You have the option to temporarily continue your coverage under COBRA. You will receive information regarding continuation of these benefits from the state’s third-party COBRA administrator, ASI COBRA. If you require a faster enrollment process, contact Employee Wellness & Benefits at 402-471-4443 or email at as.employeebenefits@nebraska.gov.

If you have any questions about COBRA, please contact ASI COBRA at 877-388-8331 or asicobra.com.

Click one of the following links to see the premiums:

• COBRA/Retiree Medical Premiums
• COBRA/Retiree Dental Premiums
• COBRA/Retiree Vision Premiums

Early Retiree Insurance Program

This program was created for state teammates who meet the qualifications and retire from employment between ages 55 through 64. Retirees age 65 or older at the time of Retirement and their spouse, will only be offered 18 months of COBRA continuation.

The Early Retiree Insurance Program allows a retiree and enrolled dependents to continue coverage on the state’s health, dental, vision, healthcare FSA, and EAP coverage at your own expense. The health insurance premiums include both state and active teammate costs. The teammate and dependent must be actively enrolled in the benefit on their last day of employment to continue coverage. Unlike COBRA, a dependent cannot continue coverage through the Early Retiree Insurance Program unless the teammate/retiree is also enrolled.

When Retiree Insurance Ends

1. Retiree coverage ends 1st of the month in which they turn age 65.
• Dependents will be offered to continue coverage on COBRA for 36 months or until the beginning of the month when the dependent turns age 65, whichever is sooner.
2. Spouse coverage ends 1st of the month in which they turn age 65.
3. Coverage in the health care FSA may only be continued through the remainder of the current plan year.
4. Monthly premiums are not paid in a timely manner.
5. This provision is changed in a subsequent labor contract.
6. The administrative regulation, contract provision, and/or applicable statutes are changed and continued coverage is no longer available.
7. The State of Nebraska ceases to provide group health insurance to teammates.

ASI COBRA administers the Early Retiree Insurance Program on behalf of the state. If you are eligible, you will receive enrollment documents from ASI COBRA upon retirement. Additional questions about the Retiree Health Insurance Program should be directed to AS-Employee Wellness & Benefits department at 402-471-4443 or email at as.employeebenefits@nebraska.gov.

Disability Retirement Insurance

A teammate under age 55 may retire as a result of disability. A teammate who chooses this option must first elect COBRA and once she/he is approved, the Retirement System will notify Employee Wellness & Benefits office. The individual’s coverage will be converted to the Early Retiree Health plan up to the first of the month in which the teammate reaches age 65.

Flexible Spending Accounts

ASI Flex

Health Care:If you have a balance in your Health Care Account at the time of termination, you may request reimbursement up to October 31 following the end of each Plan Year. You may claim expenses incurred through the end of the month of your termination date. If you have a positive balance in your FSA account and are eligible for COBRA, expenses incurred after your termination date will not be eligible for reimbursement unless you continue your coverage through COBRA. If you choose not to elect COBRA, and you have no incurred expenses before leaving the State of Nebraska, then those remaining funds are forfeited. You will receive information from ASI COBRA Services in a separate mailing regarding continuing your Health Care, if applicable. If you have questions, please call ASIFlex directly at 800-659-3035 or email asi@asiflex.com.

Dependent Care Account:If you have a Dependent Care Account at the time of termination, you may be reimbursed for claims incurred through the end of the current plan year up to the balance in your dependent care account at ASIFlex. The deadline for reimbursement requests is October 31 following the end of each Plan Year. If you have questions regarding your Dependent Care Account, please call ASIFlex directly at 800-659-3035 or email asi@asiflex.com.

Health Savings Account (HSA)

Optum Bank

If you have a Health Savings Account, it will continue to be owned by you after leaving the State of Nebraska. You can keep the account with Optum Bank and continue to use the money for qualified healthcare expenses. You may be able to make personal contributions to the account or roll over the account into a new HSA. Contact Optum Bank at 800-791-9361 for assistance.

Employee Assistance Program (EAP)

Deer Oaks

Deer Oaks offers free and confidential Work/Life benefits to you and your family up to 18 months after termination. Visit www.deeroakseap.com. Company ID and Password = SON. Please note: not all agencies offer an EAP through Deer Oaks.

Long Term Disability (LTD)

UnitedHealthCare

Your Long Term Disability policy ends at midnight the day you terminate. You may continue your long term disability coverage under a Portability Policy. A Portability Application is available on the Employee Wellness & Benefits web page at das.nebraska.gov/personnel/wellness. Please contact UnitedHealthcare at 877-683-8601 within 31 days of your termination if you would like to take advantage of the Portability Policy.

Short Term Disability is not portable upon leaving employment with the State of Nebraska.

Basic & Voluntary Life

The Hartford

Your life insurance benefits end on the last day of the month in which you terminate. Participants may convert a portion to a private plan. Please contact The Hartford directly at 877-320-0484 within 31 days of your termination date for information on how to convert your policy. A conversion form is available on the Employee Wellness & Benefits website at das.nebraska.gov/personnel/wellness.

Need Help?

If you require additional assistance after contacting the appropriate vendors, please contact Employee Wellness & Benefits at 402-471-4443 (in Lincoln) or 877-721-2228 (outside Lincoln) or via email as.employeebenefits@nebraska.gov.

The State of Nebraska wishes you luck in your future endeavors!

COBRA and Retiree Medical, Dental, and Vision Premiums

Legal Notifications

Summary Plan Documents

Plan documents are accessible through the Employee Wellness & Benefits page at das.nebraska.gov/personnel/wellness.

Women’s Health and Cancer Rights Act of 1998 (WHRCA)

The Women’s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patients benefits for:

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

Your state-sponsored health coverage plans comply with these requirements. Benefits for these items generally are comparable to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by the patient and her physician. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information about WHCRA required coverage, you can contact the plan administrator at 402-471-4443.

Mental Health Parity Act

The Mental Health Parity and Addiction Equity Act of 2008 prohibit separate treatment limits for mental illness and substance abuse. It requires equivalent cost sharing and out-of- pocket expenses for these benefits. Coverage must have the financial requirements as any other illness including: deductibles and coinsurance.

Services must still be provided by a qualified physician or licensed psychologist, licensed special psychologist, licensed clinical social worker, licensed mental health practitioner, or auxiliary providers supervised by a qualified physician.

Benefits for ALL inpatient admissions must be pre-certified.

Notice of Special Enrollment

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

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

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligi-ble for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2022. Contact your State for more information on eligibility –

To see if any other states have added a premium assistance program since January 31, 2022, or for more information on special enrollment rights, contact either:

U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)

U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565

OMB Control Number 1210-0137 (expires 1/31/2023)

MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 0938-0990

FOR USE ON OR AFTER APRIL 1, 2011

Important Notice from State of Nebraska About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with State of Nebraska 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. State of Nebraska has determined that the prescription drug coverage offered by the State of Nebraska is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

Members that become eligible for Medicare part D can keep this coverage if they elect part D and this plan will co-ordinate with Part D coverage.

If you do decide to join a Medicare drug plan and drop your current State of Nebraska coverage, be aware that you and your dependents will not be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with the State of Nebraska and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through State of Nebraska changes. You also may request a copy of this notice at any time.

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:

1. Visit www.medicare.gov
2. 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
3. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

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

Date: April 14, 2017

Name of Entity/Sender: State of Nebraska

CMS Form 10182-CC

Updated April 1, 2011

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

MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 0938-0990 FOR USE ON OR AFTER APRIL 1, 2011
Contact--Position/Office: DAS Employee Wellness & Benefits Address: 1526 K Street, Suite 110, Lincoln, NE 68508 Phone Number: 402-471-4443

MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE OMB 0938-0990

FOR USE ON OR AFTER APRIL 1, 2011

Statement of Rights under the Newborns’ and Mothers’ Health Protection Act

Under Federal law, group health Plans and health insurance issuers offering group health insurance coverage gen-erally may not restrict Benefits for any Hospital length of stay in connection with childbirth for the mother or new-born child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the Plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.

Also, under Federal law, plans and issuers may not set the level of Benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, a plan or issuer may not, under Federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain prior authorization or notify the Claims Administrator. For information on notification or prior authorization, contact your issuer.

NOTICE OF PRIVACY PRACTICES OF CERTAIN GROUP HEALTH PLANS

SPONSORED BY STATE OF NEBRASKA

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.

Each Group Health Plan in which you participate is required by federal law to maintain the privacy of your personal health information. Each Plan is also required to give you a Notice which describes its privacy practices, its legal duties and your rights concerning such information. This is the required joint Notice for all group health plans sponsored by State of Nebraska, collectively referred to in this Notice as (the “Plan Sponsor”):

Uses and disclosures of your information

The Plan is permitted or required to use or disclose your health information without your authorization (permission) to carry out certain services and activities. Health information includes medical information involving your diagnosis or treatment, insurance information, and health care claims and payment information. Many of those services or activities are performed through contracts with outside persons or organizations, such as auditing, actuarial services, administrative services, legal services, etc. It may be necessary for the Plan to provide certain of your health information to these outside persons or organizations who assist the Plan with these functions or activities. The Plan requires these persons and entities to appropriately safeguard the privacy of your information.

The following are the types of uses and disclosures the Plan may make of your health information without your authorization. Where State or federal law restricts one of the described uses or disclosures, the Plan will follow the requirements of such State or federal law. The following are general descriptions only. They do not cover every example of a disclosure within a category.

Treatment. The Plan will make disclosures of your health information as necessary for your treatment. For instance, a doctor or health facility involved in your care may request certain of your health information that the Plan maintains in order to make decisions about your care. We will disclose your medical information to your physician and other practitioners, providers and health care facilities for their use in treating you.

Payment. The Plan will use and disclose your health information as necessary for payment purposes. For example, the Plan may use and disclose your health information to pay claims from doctors, hospitals and other providers for services delivered to you that are covered by your health plan, to determine your eligibility for benefits, to determine whether services are medically necessary or to pre-authorize or certify services as covered under your plan of benefits. We may also disclose medical information about you to other health care providers and health plans for their payment purposes. For example, if you have other health coverage, the Plan may disclose your health information to other health care programs or insurance carriers in order to coordinate payment of benefits. The Group Health Plans jointly following this Notice will share your health information for purposes of payment.

Health Care Operations. The Plan will use and disclose your health information as necessary for the Plan’s Health Care Operations. For example, the Plan may use and disclose your medical information to conduct quality improvement activities, engage in care coordination or to purchase reinsurance coverage. The Plan may also disclose your health information to another Covered Entity for purposes of that entity’s Health Care Operations. For example, another health plan or health care provider may request your health information for purposes of conducting quality assurance and improvement activities, or accreditation, certification, licensing or credentialing activities. The Group Health Plans jointly following this Notice will share your health information for purposes of joint Health Care Operations of the Plan.

Plan Sponsor. The Plan may disclose your health information to the Plan Sponsor to permit the Plan Sponsor to perform plan administration functions on behalf of the Plan. The Plan may disclose “Summary Health Information” to the Plan Sponsor for obtaining bids or for the purpose of amending or terminating the Plan. “Summary Health Information” includes claim history, claim expenses and types of claims by individuals without including any personally identifying information. The Plan may also disclose to the Plan Sponsor information on whether you are participating in the Plan. If the Plan discloses any other health information to the Plan Sponsor without your authorization, the Plan documents will restrict how the information is used and prevent it from being used to make employment decisions about you. The Plan documents restrict the uses and disclosures that the Plan Sponsor may make of your health information, and require the Plan Sponsor to certify that the information provided will be maintained in a confidential manner and not used for employment-related decisions or for other employee benefit determinations without your authorization or in any other manner not permitted by law or the Plan documents.

Information Received Prior to Enrollment. The Plan may receive from you and your health care providers health information prior to your enrollment in the Plan. The Plan will not use or further disclose this health information for any purpose, except as required by law, unless you enroll in the Plan. After enrollment, uses and disclosures are governed by the terms of the Notice then in effect.

Friends and Family. The Plan may disclose health information to family members or friends who are involved in your care or payment for your care to facilitate that person’s involvement in caring for you or paying for your care. If you are present, the Plan will give you the opportunity to object before it makes such disclosures. If you are unavailable, incapacitated or are in an emergency situation, the Plan may disclose limited information to these persons if the Plan determines disclosure is in your best interest.

Disaster Relief. The Plan may use or disclose your name, location and general condition or death to a public or private organization authorized by law or by its charter to assist in disaster relief efforts.

Deceased Individuals. The Plan may disclose the health information of a deceased individual to a coroner, medical examiner or funeral director to carry out their duties as allowed by law.

Organ Donation. If you are an organ donor, or recipient, the Plan may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation.

Research. The Plan may use or disclose your medical information for research purposes in accordance with certain safeguards.

Law Enforcement. The Plan may disclose your health information to law enforcement authorities for law enforcement purposes, such as reporting wounds of violence and physical injuries or other similar disclosures allowed by the law; in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness or missing person; if you are the victim of a crime, but only if your agreement is obtained or, under certain limited circumstances, if the Plan is unable to obtain your agreement; about a death which is believed to be the result of criminal conduct; and in emergency circumstances, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. The Plan must comply with federal and state laws in making such disclosures.

Public Health Activities. The Plan may disclose medical information about you for public health activities. These activities may include disclosures to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury or disability; to appropriate authorities authorized to receive reports of child abuse and neglect; to the Food and Drug Administration (FDA) or a person subject to the jurisdiction of the FDA for purposes of monitoring or reporting the quality, safety or effectiveness of FDA-regulated products; or to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

Abuse, Neglect and Domestic Violence. The Plan may notify the appropriate government authority if it believes you have been the victim of abuse, neglect or domestic violence. Unless such disclosure is required by law, the Plan will only make this disclosure if you agree or, if unable to obtain your agreement, under other limited circumstances when authorized by law.

To Avert a Serious Threat To Health or Safety. Under certain circumstances the Plan may use or disclose Protected Health Information if, in good faith, the use or disclosure is necessary to prevent or lessen the threat and is to a person reasonably able to prevent or lessen the threat (including the subject of the threat) or, under limited circumstances, is necessary for law enforcement authorities to identify or apprehend an individual involved in a crime.

Military and National Security. The Plan may release your health information if you are a member of the armed forces as required by military command authorities. It may also release medical information about foreign military personnel to the appropriate foreign military authority. The Plan may also release your health information to federal authorities, if necessary, for national security or intelligence activities authorized by law.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, the Plan may disclose your Protected Health Information to the correctional institution or to a law enforcement official for (1) the institution to provide health care to you, (2) your health and safety and the health and safety of others, or (3) the health and security of the correctional institution.

Legal Proceedings. If you are involved in a lawsuit or a dispute, the Plan may disclose medical information about you in response to a court or administrative order. The Plan may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if reasonable efforts have been made to notify you of the request or to obtain an order from the court protecting the information requested.

Workers’ Compensation. The Plan may disclose your health information to comply with workers’ compensation laws or other similar programs providing benefits for work-related injuries.

Health Oversight Activities. The Plan may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Required by Law. The Plan will disclose health information about you when required to do so by federal or state law, including disclosures to the U.S. Department of Health and Human Services upon request for purposes of determining the Plan’s compliance with federal law.

Incidental Uses and Disclosures. There are certain incidental uses or disclosures of your information that occur while we are providing service to you or conducting our business. We will make reasonable efforts to limit these incidental uses and disclosures.

Other Uses and Disclosures. Other uses and disclosures of your medical information not covered above will be made only with your written authorization. If you authorize us to use and disclose your information, you may revoke that authorization at any time. Such revocation will not affect any action we have taken prior to the revocation in reliance on your authorization.

Individual Rights

Access to Your Health Information. You have the right to copy and/or inspect the health information that the Plan maintains on your behalf, with limited exceptions. All requests for access must be made in writing and signed by you or your representative. If you request copies, the Plan may charge you a reasonable, cost-based fee for each page, plus an additional amount for postage if you request a mailed copy. If you prefer, the Plan may agree to prepare a summary or an explanation of your health information and may charge a fee to prepare such summary.

Amendment to Your Health Information. You have the right to request in writing that the health information the Plan maintains about you be amended or corrected. The Plan is not obligated to make all requested amendments but will give each request careful consideration. For example, if the Plan did not create the information, your request will be denied. If the Plan denies your request, you will be provided with a written explanation and an explanation of your rights. All amendment requests must be in writing, signed by you or your representative, and must state the reasons for the requested amendment.

Accounting for Disclosures of Your Health Information. You have the right to receive an accounting of certain disclosures made by the Plan of your personal health information after April 14, 2004. Requests must be made in writing and signed by you or your representative. The first accounting in any 12-month period is free; you may be charged a fee for each subsequent accounting you request within the same 12-month period.

Request for Voluntary Restrictions on Use and Disclosure. You have the right to request that the Plan voluntarily place additional restrictions on its use or disclosure of your health information for treatment, payment, Health Care Operations or to persons you identify. The Plan is not required to agree to these additional restrictions, but if it does, it will abide by the agreement (except in an emergency). To be effective, any agreement by the Plan must be in writing signed by a person authorized to make such an agreement on the Plan’s behalf. The Plan retains the right to terminate any agreed to restriction upon notification to you of such termination. The termination will only be effective for health information received after providing notice to you.

Confidential Communications. You have the right to request that the Plan communicate with you about your health information by alternative means or at an alternative location. You must make your request in writing to the address listed at the end of this Notice. The Plan is required to accommodate reasonable requests if you inform the Plan that disclosure of all or part of your information could place you in danger, specify the alternative means or location and continue to permit the Plan to collect premiums and pay claims under your health plan, including issuance of explanation of benefits to the subscriber of Plan in which you participate.

Complaints. If you have concerns about any of the Plan’s privacy practices or believe that your privacy rights may have violated. You may also submit a written complaint to the U.S. Department of Health and Human Services. The Plan supports your right to protect the privacy of your health information. Neither the Plan nor the Plan Sponsor will retaliate in any way if you chose to file a complaint with the Plan or with the U.S. Department of Health and Human Services.

Exercising Your Rights. The Plan contracts with outside administrators (the “Administrator”) to actually administer and operate the Plan. Under the terms of the arrangement, it is the Administrator, not the Plan, which creates, maintains and uses most or all of the medical information about you. To exercise the individual rights described in this Notice, or to file a complaint, contact:

About this Notice

The Plan is required to abide by the terms of the Notice currently in effect. The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all of your personal health information that it maintains, including that which it created or received while the prior Notice was in effect. If the Plan makes a material change to its privacy practices, it will revise its Notice and provide you with a copy of the revised Notice.

If you receive this Notice by electronic mail (e-mail), you are entitled to receive this Notice in written form. Please contact the Privacy Officer at the address listed below to obtain a written copy of this Notice.

Contact Information

PRIVACY OFFICER: For questions about this Notice, contact the Plan’s Privacy Officer at:

Wellness & Benefits Administrator
Attn: HIPAA Privacy Officer
1526 K Street, Suite 110
Lincoln, NE 68508

402-471-2832

EFFECTIVE DATE OF NOTICE: April 1, 2017