20250224GSW to Staff 17 Attachment 2.pdf

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Employee Benefits Guide 2024-2025
NW Natural Water
Plan Year: 12/01/2024 - 11/30/2025
PaYG�P A- X
IPUC i� °�! PAe � �ruance
Page 1 of 27

Table of Contents
• Overview . Life and Accidental Death and
• How to Enroll Dismemberment Insurance
• Medical Insurance . Voluntary Insurance
• Dental Insurance • BalanceCare® Health Advocacy Services
• Vision Insurance • Additional Information: Plan Notices,
Disclosures, and Legal Documents
• Disability Insurance
Insurance Provider Contact Information
Carrier Phone Number Website
Medical & Prescription Drugs
Regence [phone] www.regence.com
Dental
Regence [phone] www.regence.com
Vision
Reliance —VSP Network [phone] www.vsp.com
Paychex Health Advocacy Service
BalanceCare° by ENI 877-598-8617 www.eniweb.com
Life/Accidental Death & Disability
Reliance [phone] www.reliancematrix.com
Disability
Reliance [phone] www.reliancematrix.com
Accident
Reliance [phone] www.reliancematrix.com
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Welcome to the NW Natural water health
benefits booklet for 2024-2025
Welcome to your benefits program. We value the contributions every employee makes to our company's success
and reward your hard work with a broad range of valuable benefits designed with the needs of our diverse
population in mind.
This guide summarizes the health and benefits plan options available for 2024-2025 with additional
information on plan notices, disclosures, and legal requirements. Please review this information as well as the
Summary of Benefits from each of the insurance providers so you can make the most informed decisions for
you and your family.
Newly Hired Employees
If you're a newly hired employee, eligible employees may elect to begin health insurance benefits first of the
month following their date of hire. If you do not enroll at the time you are first eligible, you will have to wait
until the next open enrollment period.
Medicare Coverage
If you elect to enroll in an employer-sponsored health plan, please notify us if you or a dependent becomes
eligible for Medicare, as we are required to notify your insurer. When you become eligible for Medicare, you are
also required to notify Medicare directly that you have group health coverage. Visit medicare.gov or call
800-MEDICARE (800-633-4227)for more information.
Glossary of Terms
We've sprinkled definitions of commonly used medical and insurance terms through this booklet. For a list of
additional terms, please visit healthcare.gov/glossary/
Note: This booklet is intended to provide only the highlights of your benefits; see your plan documents for the
benefit or contact the benefits department at [e-mail] or(971) 320-5291 for more
details. If any conflict ever arises between this booklet and the plan documents, the terms of the plan
documents will govern in all cases. NW Natural Water reserves the right to change, modify, or terminate the
plan as set forth in the plan document. This booklet is not a contract for purposes of employment or payment
of benefits. To receive benefits, you must be eligible to enroll in the plan and enroll as required by the plan.
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How to Enroll
Benefits Elections
Acceptance/Refusal of Coverage form
• Policy information is required if covered under another plan
• Dates of birth and social security numbers are required for employee and dependents
• Indicate plan type and level of coverage
• Complete online through Paychex Flex° (see instructions on next page)
Changing Your Benefits
• You will not be able to make changes to your plan
midyear unless you experience a qualifying life event, Qualifying Event
which may allow you and your dependents to enroll A change in status or a "qualifying
in health insurance outside of the yearly open event" is defined as:
enrollment period.
Marriage
• If you experience a qualifying event, you have 30 days
• Divorce or legal separation
to report that event to the plan administrator or through
Paychex Flex and make the appropriate changes to your . Birth or adoption of a child
plan. Otherwise the plans that you enroll in will remain in
effect until 11/30/2025. The next opportunity A change in your or your spouse's
employment or insurance status
to make a change to benefits is during the next annual
enrollment time period. • A dependent ceasing to meet
eligibility requirements
• A change in residence that
affects coverage
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Mobile Access
Made Simple
LTEM, The Mobile App for Paychex Flex
demo.paychex.ccm C; The mobile app for Paychex Flex gives you easy access to
your employee benefits, pay stubs, tax forms, and more —even
A° while you're away from work. With the tap of an icon, securely
ABC Company C:) log in to view your payroll and benefits data whenever and
wherever you need it. Eligible Android, Phone, and Pad
< Payroll Center customers can access the app with the security and
Check Date: Nov 5 O convenience of fingerprint and Touch ID capabilities.
Pay Period:Oct 21-Nov 5,2018
Download the Mobile App for Paychex Flex
More Options
Download the app for your smartphone or tablet from the
TOTAL CHECKS 10 Apple,, App StoresM or the Google PlayTM store.
TOTAL HOURS 295.20
ANDROIDAPPON
TOTALAMOUNTS $6,249.66 ` • • Store
•
GSW-W-24-01
q Search by Name or ro IPUC Staff PR 17 Attachment 2
Page 5 of 27
Pay All

Time-saving features that keep you •
connected and in control: "
• Direct Deposit. Set up or change your direct � 1
deposit information.
• Check Stubs. Easily access your statements • Y
any time to see net pay, deductions, and pay
date. You don't need to wait for a pay stub or
find a computer to log in to.
• FSA. Keep track of important information about
unreimbursed medical/dental and dependent ( � ,
care expenses, reimbursements, elections, ,
claims history, and debit cards.
• Retirement. Quickly check your retirement
accounts, investment balance, performance,
and loan information. Change your
contributions and investment allocations as Best of all — it's free!
needed.
How to get started
• My Profile. View your employee profile
information, including work and personal First, complete your Paychex Flex single-sign-
details, pay/compensation, earnings, federal on account registration at paychexflex.com
and state taxes, unemployment, and using a desktop or laptop computer connected
deductions. Edit your personal profile to the internet.
information as needed and access messages,
For more information about using the mobile
all from within the app. app for Paychex Flex, visit the Paychex mobile
• Tax Documents. Access your W-2 and 1099 support site to download the User Guide for
forms online to make tax time easier. Employees: payx.me/flexmobile
• Health and Benefits. Review all your benefits
data—coverage elections and types, eligibility
date and status, premium amounts, member
guide, and links to carrier information. Enroll
from right within the mobile app.
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I UC Staff PR 17 Attachment 2
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Medical Insurance Plans
JF Helpful Terms -.M=d
Copay
r
A fixed dollar amount that you may
N�
pay for certain covered services.
Typically, your copay is due up
front at the time of service.
Aft
Coinsurance
After you meet your deductible, you
may pay coinsurance, which is your
share of costs of a covered service.
Deductible
The amount that you must a
Y pay
each year for certain covered
r health services before the
jinsurance plan will begin to pay.
Out-of-Pocket Maximum
Includes copays, deductibles, and
` coinsurance. Once you meet this
+�^ amount, the plan will pay 100% of
• covered in-network services the
rest of the year.
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IPUC Staff PR 17 Attachment 2
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Medical Insurance
Example of How You Share Costs with Your Insurer
Jane's Plan Deductible: $1,500 1 Coinsurance: 20% Out-of-Pocket Limit: $5,000
January 1
Beginning of Coverage Period
Jane hasn't reached her$1,500 deductible yet Office visit cost: $ 150
Jane pays Her plan pays 0%: $ 0
Her plan doesn't pay any of the costs. 100% Jane pays 100%: $ 150
Additional costs that count toward deductible: prescriptions, office visits,
hospital visits
Jane reaches her$1,500 deductible, coinsurance begins
Office visit cost: $ 150
Jane has seen a doctor several times and paid $1,500 in total. Jane pays Her plan pays 80%: $ 120
Her plan pays some of the costs for her next visit. 20% Jane pays 20%: $ 30
Additional costs that count toward deductible: prescriptions, office visits,
hospital visits
Jane reaches her$5,000 out-of-pocket limit
Jane has seen the doctor often and paid $5,000 in total. Her Plan pays Office visit cost: $ 150
100% Her plan pays 100%: $ 150
plan pays the full cost of her covered healthcare services for Jane pays 0%:
the rest of the year.
December 31
End of Coverage Period
Source:https://www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/sbc-uniform-glossary-of-
coverage-and-medical-terms-fina1.pdf
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Medical Insurance Comparison
Effective Date and Policy Year Option 1 Option 2
December - . -
Benefit Plan Name HSA 1 Classic
$2,500 111 11 11
Deductible Deductible
Preventive Care 100% 100%
Deductible (Individual/Family) $2,500 / $5,000 $500 /$1,500
Coinsurance 80% 80%
Out-of-Pocket Max (Individual/Family) $5,000 / $10,000 $3,000 / $6,000
Primary Care Physician No Charge/ First 3 visits, $5 copay/ First 3 visits,
Deductible then 20% $20 copay after the 3
Virtual/Telemedicine Copay See Plan Summary See Plan Summary
Specialist Deductible then 20% $20 copay
Urgent Care Deductible then 20% $20 copay
Emergency Room Copay Deductible then 20% $150 copay
Deductible then 20%
Inpatient Hospital Deductible then 20% Deductible then 20%
Outpatient Surgery— Facility Deductible then 20% Deductible then 20%
Diagnostic X-Ray Lab Deductible then 20% Deductible then 20%
Prescription Deductible $0 $0
Prescription Copay Deductible then 20% $10 / $35/ $75
M=— ,=
Deductible (Individual/Family) Shared with In Network Shared with In Network
Coinsurance 60% 60%
Out-of-Pocket Max (Individual/Family) Shared with In Network Shared with In Network
GSW-W-24-01
Note:This chart shows only the highlights of your medical plan benefits. Please see the Evidence of Cove'��fo 8ffipy&Vir�fdr� GA%W� h;plan
benefits,exclusions,and limitations. Page 9 of 27

Dental Insurance Plans
HelpfulAV
� 00* Deductible
The amount that you must pay each
year before Basic, Major Services,
and Orthodontia (when applicable)
are covered in addition to the
specified coinsurance.
Annual Maximum Benefit
e"o , The total benefit payable by the
plan will not exceed the highest
p listed maximum amount for either
` �=^ Network or Non-Network services.
MA
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Dental Insurance Comparison
DentalBenefit Plan Name
Deductible Single Family
In Network or Out of Network $50 $150
Annual Maximum Benefit ■
In Network or Out of Network $2,000
Diagnostic Services —Tier 1 In Network Out of network
Periodic Oral Evaluation 100% 100%
X-Rays 100% 100%
Lab and Other Diagnostic Tests 100% 100%
Preventative Care—Tier 1
Dental Prophylaxis (Cleanings) 100% 100%
Fluoride Treatments 100% 100%
Basic Dental Services —Tier 2
Sealants 80% 80%
Restorations (Fillings) 80% 80%
Endo/Periodontics (nonsurgical) 80% 80%
Simple Extractions 80% 80%
Major Dental Services —Tier 3
Space Maintainers 50% 50%
Periodontics (surgical) 50% 50%
Endodontics (surgical) 50% 50%
Inlays/Onlays/Crowns 50% 50%
Dentures & Fixed Partial 50% 50%
Orthodontic Services —Tier 3
Ortho Coverage Not Covered Not Covered
GSW-W-24-01
Note:This chart shows only the highlights of your medical plan benefits. Please see the Evidence of CovewcJX 89PY&I-JOAHA A;plan
benefits,exclusions,and limitations. Page 11 of 27

Vision Insurance Plans
Helpful Terms
Allowance
The amount that your vision carrier
`T will cover for your frames or lens
enhancements.
What's the difference
between elective and
necessary contacts?
Elective—When vision can be
corrected by glasses, but contacts
I are worn.
Necessary—When vision can't be
corrected with glasses due to
f� extreme vision problems.
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Vision Insurance Comparison
December ,
Network
Benefit Plan Name f Vision
Benefit Frequency (Based on date of service)
Comprehensive Exam 12 months
Eyeglass or Contact Lenses 12 months
Frames 12 months
Copays In Network Out of network
Exam(s) $10 copay $10 copay
Materials $25 copay $25 copay
Frame Benefit (allowance)*
Fram Allowance $130 Up to $70
*Additional discount exceeding 20% savings on the amount that you pay
frame allowance over your allowance. Varies depending
on participating locations.
Eyeglass lenses
Single Vision No additional cost Up to $30
after $25 co-pay
Bifocal No additional cost Up to 50
after $25 co-pay
Trifocal No additional cost Up to $65
after $25 co-pay
Lenticular No additional cost Up to $100
after $25 co-pay
Contact Lens Benefits
Fit and Follow-up Exams $60 No benefit
Contacts Elective Up to $130 Up to $105
Medically Necessary
Eyeglasses or Contacts No additional cost Up to $210
after $25 co-pay
GSW-W-24-01
Note:This chart shows only the highlights of your vision plan benefits. Please see the Evidence of Cove raj@Wc&4j 0n167rM&f i Dan
benefits,exclusions,and limitations. Page 13 of 27

Disability Insurance — Overview
Helpful
do
Pre-existing Condition
A condition you've been diagnosed
with or have encountered
symptoms of prior to applying for
coverage. In some policies, this
condition won't be covered or there
will be a timeframe that you must
be insured before it's covered.
Elimination Period
The length of time between the
~ ��1► beginning of an injury or illness and
, . . " receiving benefit payments from
an insurer.
Short-term and Long-term Disability
Short-term Disability (STD)
A type of insurance benefit that can replace up to a specified percentage of an eligible employee's income
when the employee is disabled and unable to work due to illness or an accident.
Long-term Disability (LTD)
A type of insurance benefit that can replace up to a specified percentage of an eligible employee's
income when the employee is disabled and unable to work due to illness or an accident, after STD has
been exhausted.
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Life and Accidental Death and
Dismemberment (AD&D) Insurance
I � E
1 i
I
Employer-paid Term Life & AD&D and Supplemental Term Life & AD&D
Helpful Terms
Guaranteed Issue Evidence of Insurability
A requirement that health plans must permit Proof of good health required to be submitted to
you to enroll regardless of health status, age, the insurer and approved by the insurer to receive
gender, or other factors that might predict the a higher Life/AD&D amount up to the specified
use of health services. Except in some states, maximum offered.
guaranteed issue doesn't limit how much
you can be charged if you enroll.
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BalanceCare® Health Advocacy Services
BalanceCare can assist
� . with services such as:
• Claims assistance
Benefit coverage verification
.t
`► . ID cards
- . Prescription drug coverage
questions
Appeals
'l HSA questions
• Health benefit education
\ Provider research
BalanceCare is a complimentary, comprehensive, time-saving resource that will help you better
understand and maximize your healthcare benefits. Our wide-ranging health advocacy services
help manage and resolve benefit plan questions for you and your family at no cost to you.
Services
Our licensed Care Guides are available to provide benefit information and assistance navigating
your health plan. Care Guides provide healthcare claims and appeals management, healthcare
billing assistance, prescription information and costs, as well as provider research.
Contact BalanceCare at 877-598-8617
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Additional Information: Plan Notices,
Disclosures, and Legal Documents
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Page 17 of 27

New Health Insurance Marketplace Coverage Form Approved
a OMB Control Number 1210-0137
Options and Your Health Coverage (expires 1/31/2023)
PART A: General Information
To assist you as you evaluate options for you and your family,this notice provides some basic information about the Health
Insurance Marketplace and employment-based health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers
"one-stop shopping"to find and compare private health insurance options.You may also be eligible for a new kind of tax credit that
lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in
October 2024 for coverage starting as early as January 1, 2025.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your
household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit
through the Marketplace and may wish to enroll in your employer's health plan. However,you may be eligible for a tax credit that
lowers your monthly premium, or a reduction in certain cost sharing if your employer does not offer coverage to you at all or does
not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other
members of your family) is more than 9.5%of your household income for the year, or if the coverage your employer provides does
not meet the"minimum value"standard set by the Affordable Care Act,you may be eligible for a tax credit.'
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer,then you
may lose the employer contribution (if any)to the employer-offered coverage.Also,this employer contribution—as well as your
employee contribution to employer-offered coverage—is often excluded from income for federal and state income tax purposes.
Your payments for coverage through the Marketplace are made on an after-tax basis.
How Can I Get More Information?
For more information about the coverage offered by your employer, please check your summary plan description or contact:
Deborah Davis at [e-mail] or(971)320-5291.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and
its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact
information for a Health Insurance Marketplace in your area.
An employer-sponsored health plan meets the"minimum value standard"if the plan's share of the total allowed benefit costs
covered by the plan is no less than 60%of such costs.
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PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an application for
coverage in the Marketplace,you will be asked to provide this information.This information is numbered to correspond to the
Marketplace application.
3. Employer name 4. Employer Identification Number(EIN)
NW Natural Water 82-4649867
5. Employer address 6. Employer phone number
220 NW 2nd Ave. [phone]
7.City 8.State 9.ZIP code
Portland OR 97209
10.Who can we contact about employee health coverage at this job?
Deborah Davis
11. Phone number(if different from above) 12. Email address
[phone] [e-mail]
Here is some basic information about health coverage offered by this employer:
As your employer,we offer a health plan to:
All employees.
X Some employees. Eligible employees are: Please see plan policies
With respect to dependents:
X We do offer dependent coverage.
We do not offer coverage for dependents.
X If checked,this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable,
based on employee wages.
1 Even if your employer intends your coverage to be affordable,you may still be eligible for a premium discount through the Marketplace.The Marketplace will use your
household income,along with other factors,to determine whether you may be eligible for a premium discount.If,for example,your wages vary from week to week
(perhaps you are an hourly employee or you work on a commission basis),if you are newly employed midyear,or if you have other income losses,you may still qualify for
a premium discount.
If you decide to shop for coverage in the Marketplace,HealthCare.gov will guide you through the process.Here's the employer information you'll enter when you visit
HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.
Source: https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/affordable-care-act/for-employers-and-
advisers/model-notice-for-employers-who-offer-a-health-plan-to-some-or-all-employees.pdf
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Notice Regarding Special Enrollment Rights
If you are declining enrollment for yourself or your dependents(including your spouse)because of other health insurance or group
health plan coverage,you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for
that other coverage(or if the employer stops contributing toward your or your dependents' other coverage). However,you must
request enrollment within 30 days after your or your dependents'other coverage ends(or after the employer stops contributing
toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for
adoption,you may be able to enroll yourself and your dependents. However,you must request enrollment within 30 days after the
marriage, birth,adoption, or placement for adoption.To request special enrollment or obtain more information, contact Deborah Davis
at(971)320-5291 or [e-mail].
Source: https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/compliance-assistance-
auide.pdf
Notice Regarding Women's Health and Cancer Rights Act (Janet's Law)
Do you know that your plan, as required by the Women's Health and Cancer Rights Act of 1998, provides benefits for mastectomy-
related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses,and
complications resulting from a mastectomy, including lymphedema? Call your plan administrator at [phone] for
more information.
Source: https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/compliance-
assistance-guide-appendix-c.pdf
Notice Regarding Michelle's Law:
Under the Affordable Care Act, group health plans and issuers are generally required to provide dependent coverage to age 26
regardless of student status of the dependent. Nonetheless, under some circumstances, such as a plan that provides dependent
coverage beyond age 26, Michelle's Law provisions may apply.
Medically necessary leave of absence means with respect to a dependent child in connection with a group health plan or health
insurance coverage offered in connection with a group health plan, a leave of absence from or other change in enrollment status in
a postsecondary educational institution that begins while the child is suffering from a serious illness or injury; is medically
necessary; and causes the child to lose student status for purposes of coverage under the terms of the plan or coverage.
A dependent child is a beneficiary who is a dependent child under the terms of the plan or coverage of a participant or beneficiary
under the plan or coverage and who was enrolled in the plan or coverage on the basis of being a student at a postsecondary
educational institution immediately before the first day of the medically necessary leave of absence involved.
A group health plan or issuer shall not terminate coverage of a dependent child due to a medically necessary leave of absence
that causes the child to lose student status before the date that is the earlier of:
• the date that is one year after the first day of the medically necessary leave of absence; or
• the date on which such coverage would otherwise terminate under the terms of the plan or health insurance coverage. See
ERISA section 714(b).
Tip: The group health plan or issuer can require receipt of written certification by a treating physician of the dependent child which
states that the dependent child is suffering from a serious illness or injury and that the leave of absence(or other change of
enrollment)is medically necessary.
Source:https://webapps.dol.gov/elaws/ebsa/health/employer/657.asp
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Notice Regarding Patient Protection Rights
Regence generally allows the designation of a primary care provider.You have the right to designate any primary care provider who
participates in our network and who is available to accept you or your family members. Until you make this designation, Regence
designates one for you. For information on how to select a primary care provider, and for a list of the participating primary care
providers, contact the Regence at(888)675-6570 or go to www.Regence.com.
For children,you may designate a pediatrician as the primary care provider.
You do not need prior authorization from Regence or from any other person (including a primary care provider)in order to obtain
access to obstetrical or gynecological care from a healthcare professional in our network who specializes in obstetrics or gynecology.
The healthcare professional, however, may be required to comply with certain procedures, including obtaining prior authorization for
certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating healthcare
professionals who specialize in obstetrics or gynecology, contact Regence at www.Regence.com.
Source: https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/compliance-
assistance-auide.pdf
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 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 877-KIDS-NOW or visit
insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay
the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer
plan,your employer must allow you to enroll in your employer plan if you aren't already enrolled.This is called a"special
enrollment"opportunity, and you must request coverage within 60 days of being determined eligible for premium
assistance. If you have questions about enrolling in your employer plan,contact the Department of Labor at askebsa.dol.gov
or call 866-444-EBSA(3272).
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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, 2021. Contact your state for more
information on eligibility.
ALABAMA—Medicaid GEORGIA—Medicaid
Website: https://www.myalhipp.com/ Website: https://medicaid.georgia.gov/third-party-liability/health-
Phone:[phone] insurance-premium-payment-program-hipp
Phone:[phone] ext 2131
ALASKA—Medicaid INDIANA—Medicaid
The AK Health Insurance Premium Payment Program: Healthy Indiana Plan for low-income adults 19-64:
Website: http://myakhipp.com/ Website: http://www.in.gov/fssa/hip/
Phone:[phone] Phone:[phone]
Email:CustomerService(cDMyAKHIPP.com All other Medicaid:
Medicaid Eligibility Website: Website:hftps://www.in.gov/medicaid/
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx Phone:[phone]
ARKANSAS—Medicaid IOWA—Medicaid and CHIP(Hawki)
Website: https://www.myarhipp.com/ Medicaid Website: https://dhs.iowa.gov/ime/members
Phone:855-MyARHIPP(855-692-7447) Medicaid Phone:[phone]
Hawki Website: https://dhs.iowa.gov/Hawki
Hawki Phone:[phone]
HIPP Website:
https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp
HIPP Phone:[phone]
CALIFORNIA—Medicaid KANSAS—Medicaid
Health Insurance Premium Payment(HIPP)Program Website: https://www.kancare.ks.gov/
Website: http://dhcs.ca.gov/hipp Phone:[phone]
Phone:[phone]
Email: hipp(a)dhcs.ca.gov
COLORADO—Health First Colorado
(Colorado's Medicaid Program)&Child Health Plan Plus(CHP+) KENTUCKY—Medicaid
Health First Colorado Kentucky Integrated Health Insurance Premium Payment Program
Website: https://www.healthfirstcolorado.com/ (KI-HIPP)Website:
Member Contact Center:800-221-3943/State Relay 711 https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx
CHP+Website:https://www.colorado.gov/pacific/hcpf/child-health- KI-HIPP Phone:[phone]
plan-plus KI-HIPP Email: KIHIPP.PROGRAM(c�ky.gov
CHP+Customer Service: 800-359-1991/State Relay 711 KCHIP Website: hftps://kidshealth.ky.gov/Pages/index.aspx
Health Insurance Buy-In Program (HIBI)Website: KCHIP Phone:[phone]
https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program Kentucky Medicaid Website: hftps://chfs.ky.gov
HIBI Customer Service:855-692-6442
FLORIDA—Medicaid LOUISIANA—Medicaid
Website: Website:www.medicaid.la.gov or www.ldh.1a.gov/lahipp
https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/ Medicaid Hotline Phone:[phone]
hipp/index.html LaHIPP Phone:[phone]
Phone:[phone]
GSW-W-24-01
IPUC Staff PR 17 Attachment 2
Page 22 of 27

MAINE—Medicaid NEW JERSEY—Medicaid and CHIP
Enrollment Website: Medicaid Website:
https://www.maine.gov/dhhs/ofi/applications-forms https://www.state.n'.us/humanservices/dmahs/clients/medicaid/
Phone:[phone] Medicaid Phone:[phone]
TTY: Maine relay 711 CHIP Website: http://www.nofamilycare.org/index.html
Private Health Insurance Premium Webpage: CHIP Phone: [phone]
https://www.maine.gov/dhhs/ofi/applications-forms
Phone:[phone]
TTY: Maine relay 711
MASSACHUSETTS—Medicaid and CHIP NEW YORK—Medicaid
Website: https://www.mass.gov/info-details/masshealth-premium- Website: https://www.health.ny.gov/health care/medicaid/
assistance-pa Phone:[phone]
Phone:[phone]
MINNESOTA—Medicaid NORTH CAROLINA—Medicaid
Website: https://mn.gov/dhs/people-we-serve/children-and- Website: https://medicaid.ncdhhs.gov/
families/health-care/health-care-programs/programs-and- Phone:[phone]
services/other-insurance.isp
Phone:[phone]
MISSOURI—Medicaid NORTH DAKOTA—Medicaid and CHIP
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone:[phone] Phone:[phone]
MONTANA—Medicaid OKLAHOMA—Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Website: http://www.insureoklahoma.org/
Phone:[phone] Phone:[phone]
NEBRASKA—Medicaid OREGON—Medicaid
Website: http://www.ACCESSNebraska.ne.gov Website: http://healthcare.oregon.gov/Pages/index.aspx
Phone:[phone] http://www.oregonhealthcare.gov/index-es.html
Lincoln:402-473-7000 Phone:[phone]
Omaha:402-595-1178
NEVADA—Medicaid PENNSYLVANIA—Medicaid
Medicaid Website: http://dhcfp.nv.gov Website:
Medicaid Phone:[phone] https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-
Program.aspx
Phone:[phone]
NEW HAMPSHIRE—Medicaid RHODE ISLAND—Medicaid and CHIP
Website: https://www.dhhs.nh.gov/oii/hipp.htm Website: http://www.eohhs.ri.gov/
Phone:[phone] Phone:[phone],or 401-462-0311 (Direct Rlte Share Line)
Toll-free number for the HIPP program: 800-852-3345,ext 5218
GSW-W-24-01
IPUC Staff PR 17 Attachment 2
Page 23 of 27

SOUTH CAROLINA—Medicaid VIRGINIA—Medicaid and CHIP
Website: https://www.scdhhs.gov Website: https://www.coverva.org/hipp/
Phone:[phone] Medicaid Phone:[phone]
CHIP Phone: [phone]
SOUTH DAKOTA-Medicaid WASHINGTON—Medicaid
Website: https://dss.sd.gov/ Website: https://www.hca.wa.gov/
Phone:[phone] Phone: [phone]
TEXAS—Medicaid WEST VIRGINIA—Medicaid
Website: http://gethipptexas.com/ Website: http://mywvhipp.com/
Phone:[phone] Toll-free phone:855-MyWVHIPP(855-699-8447)
UTAH—Medicaid and CHIP WISCONSIN—Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/ Website:
CHIP Website: http://health.utah.gov/chip https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone:[phone] Phone: [phone]
VERMONT—Medicaid WYOMING—Medicaid
Website: http://vtww.greenmountaincare.org/ Website: https://health.wVo.gov/healthcarefin/medicaid/programs-
Phone:[phone] and-eligibilitV/
Phone:[phone]
To see if any other states have added a premium assistance program since January 31,2021, or for more information on special
enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare& Medicaid Services
www.dol.gov/agencies/ebsa www.cros.hhs.gov
866-444-EBSA(3272) 877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995(Pub. L. 104-13)(PRA), no persons are required to respond to a collection of
information unless such collection displays a valid Office of Management and Budget(OMB)control number. The department notes that
a federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA and displays a
currently valid OMB control number,and the public is not required to respond to a collection of information unless it displays a currently
valid OMB control number. See 44 U.S.C. 3507.Also, notwithstanding any other provisions of law, no person shall be subject to penalty
for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control
number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent.
Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of
Policy and Research,Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718,Washington, DC 20210 or
email [e-mail] and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023)
GSW-W-24-01
IPUC Staff PR 17 Attachment 2
Page 24 of 27

Medicare Part D Coverage Notice — Important Information 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 NW Natural Water 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. NW Natural Water has determined that the prescription drug coverage offered by the medical plan chosen by the
employee is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug
coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage,
you can keep this coverage and not pay a higher premium (a penalty)if you later decide to join a Medicare drug plan.
When Can You Join a Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a
two(2)month Special Enrollment Period (SEP)to join a Medicare drug plan.
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.
GSW-W-24-01
IPUC Staff PR 17 Attachment 2
Page 25 of 27

What Happens to Your Current Coverage If You Decide to Join a Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current NW Natural Water coverage will not be affected.
Prescription coverage by plan tier: Please see Summary of Benefits and Coverage for your prescription coverage.
If you do decide to join a Medicare drug plan and drop your current NW Natural Water coverage, be aware that you and your
dependents may 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 NW Natural Water 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 your plan administrator,who is the person listed below,for further information.
• Name of Entity/Sender: NW Natural Water
• Contact Name: Deborah Davis
• Address: 220 NW 2nd Ave., Portland, OR 97209
• Phone Number: [phone]
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 NW Natural Water changes. You also may request a copy of this notice at any time.
For more information about Your Options Under Medicare Prescription Drug Coverage:
More detailed information about Medicare plans that offer prescription drug coverage is in the"Medicare&You"handbook. You'll get a
copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For additional information about Medicare prescription drug coverage:
• Visit 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 800-MEDICARE (800-633-4227).TTY users should call 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 socialsecurity.gov, or call them at 800-772-1213(TTY 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).
GSW-W-24-01
IPUC Staff PR 17 Attachment 2
Page 26 of 27

Newborns' Act Disclosure
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).
Source: https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/compliance-
assistance-quide-appendix-c.pdf
HIPAA Privacy
The plans outlined in this booklet complies with the privacy requirements of the Health Insurance Portability and Accountability Act of
1996(HIPAA).These requirements are described in a Notice of Privacy Practices available upon request.
Insurance is sold and serviced by Paychex Insurance Agency, Inc., PAYCHEX'150 Sawgrass Drive,Rochester NY 14620.CA license#OC28207 WW
II�Lp�yrB'ef4�Qlsurance
®2021 Paychex,Inc.All Rights Reserved.1171561 Rev.04/27/21 IPUC SH Yk 177 Attac ment L
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