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HomeMy WebLinkAbout20250224GSW to Staff 17 Attachment 2.pdf �— l I 3 • �� ram_ i 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 (888) 675-6570 www.regence.com Dental Regence (888) 675-6570 www.regence.com Vision Reliance —VSP Network (800) 877-7195 www.vsp.com Paychex Health Advocacy Service BalanceCare° by ENI 877-598-8617 www.eniweb.com Life/Accidental Death & Disability Reliance (800) 351-7500 www.reliancematrix.com Disability Reliance (800) 351-7500 www.reliancematrix.com Accident Reliance (800) 351-7500 www.reliancematrix.com GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 2 of 27 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 deborah.davis@nwnatural.com 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. GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 3 of 27 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 GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 4 of 27 nf�i'•A �• " i 0 n�. • O P ppY AMA P�'e d� C+ 1 C& limp `1 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. GSW-W-24-01 I UC Staff PR 17 Attachment 2 Page 6 of 27 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. GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 7 of 27 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 GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 8 of 27 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 GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 10 of 27 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. GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 12 of 27 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. GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 14 of 27 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. GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 15 of 27 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 GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 16 of 27 Additional Information: Plan Notices, Disclosures, and Legal Documents GSW-W-24-01 IPUC Staff PR 17 Attachment 2 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 deborah.davis@nwnatural.com 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. GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 18 of 27 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. (971) 320-5291 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 (971) 320-5291 deborah.davis@nwnatural.com 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 GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 19 of 27 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 deborah.davis@nwnatural.com. 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 (971)320-5291 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 GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 20 of 27 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). GSW-W-24-01 IPUC Staff PR 17 Attachment 2 Page 21 of 27 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:855-692-5447 insurance-premium-payment-program-hipp Phone:678-564-1162 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:866-251-4861 Phone:877-438-4479 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:800-457-4584 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:800-338-8366 Hawki Website: https://dhs.iowa.gov/Hawki Hawki Phone:800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp HIPP Phone:888-346-9562 CALIFORNIA—Medicaid KANSAS—Medicaid Health Insurance Premium Payment(HIPP)Program Website: https://www.kancare.ks.gov/ Website: http://dhcs.ca.gov/hipp Phone:800-792-4884 Phone:916-445-8322 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:855-459-6328 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:877-524-4718 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:888-342-6207 hipp/index.html LaHIPP Phone:855-618-5488 Phone:877-357-3268 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:800-442-6003 Medicaid Phone:609-631-2392 TTY: Maine relay 711 CHIP Website: http://www.nofamilycare.org/index.html Private Health Insurance Premium Webpage: CHIP Phone: 800-701-0710 https://www.maine.gov/dhhs/ofi/applications-forms Phone:800-977-6740 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:800-541-2831 Phone:800-862-4840 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:919-855-4100 services/other-insurance.isp Phone:800-657-3739 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:573-751-2005 Phone:844-854-4825 MONTANA—Medicaid OKLAHOMA—Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Website: http://www.insureoklahoma.org/ Phone:800-694-3084 Phone:888-365-3742 NEBRASKA—Medicaid OREGON—Medicaid Website: http://www.ACCESSNebraska.ne.gov Website: http://healthcare.oregon.gov/Pages/index.aspx Phone:855-632-7633 http://www.oregonhealthcare.gov/index-es.html Lincoln:402-473-7000 Phone:800-699-9075 Omaha:402-595-1178 NEVADA—Medicaid PENNSYLVANIA—Medicaid Medicaid Website: http://dhcfp.nv.gov Website: Medicaid Phone:800-992-0900 https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP- Program.aspx Phone:800-692-7462 NEW HAMPSHIRE—Medicaid RHODE ISLAND—Medicaid and CHIP Website: https://www.dhhs.nh.gov/oii/hipp.htm Website: http://www.eohhs.ri.gov/ Phone:603-271-5218 Phone:855-697-4347,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:888-549-0820 Medicaid Phone:800-432-5924 CHIP Phone: 855-242-8282 SOUTH DAKOTA-Medicaid WASHINGTON—Medicaid Website: https://dss.sd.gov/ Website: https://www.hca.wa.gov/ Phone:888-828-0059 Phone: 800-562-3022 TEXAS—Medicaid WEST VIRGINIA—Medicaid Website: http://gethipptexas.com/ Website: http://mywvhipp.com/ Phone:800-440-0493 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:877-543-7669 Phone: 800-362-3002 VERMONT—Medicaid WYOMING—Medicaid Website: http://vtww.greenmountaincare.org/ Website: https://health.wVo.gov/healthcarefin/medicaid/programs- Phone:800-250-8427 and-eligibilitV/ Phone:800-251-1269 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 ebsa.opr@dol.gov 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: (971)320-5291 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 Page 27 of 27