You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate
If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995
Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not
discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender
Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio
accessible electronic formats and other formats) bull Asante provides free language services to people whose primary
language is not English including o Qualified interpreters o Information written in other languages
If you need these services contact Alicia Lorenz at the phone number or email address listed below
If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)
You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at
US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)
This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020
Asante Health Plan changesPlan names Asante Health Plan 1 is being
renamed Asante PPO Health Plan Asante Health Plan 2 is being
renamed Asante Savings HealthPlan or HSA
Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA
For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use
Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers
A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles The deductibles for the new
Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses
Rx expenses will be counted toward the medical out-of-pocket maximums
The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50
Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles The deductibles for the four
categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family
Out-of-pocket maximums The out-of-pocket maximums for the
four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family
Copay and coinsurance changes The office visit coinsurance for
primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)
The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)
The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50
Health Savings Account The HSA contribution limit has
increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage
Employer contributions to the HSA Asante contributes to your HSA
if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled
Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four
categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums
Whatrsquos new for 2020
The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50
Employer contributions to the HRA Asante contributes to your HRA
account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents
Other changes In the Asante Reimbursement
Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations
In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers
Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan
(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)
Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit
All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet
All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply
A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible
Dental plan changes The Willamette Dental plan will have
a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year
There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan
Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits
Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012
Critical illness and accident plans Certain insurance policies are
available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505
Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information
This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025
All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization
How We May Use and Disclose Your Protected Health Information
Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories
For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use
For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments
For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes
To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us
As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws
Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it
The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage
This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System
The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees
What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage
If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen
1 Your hours of employment are reduced or
2 Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens
1 Your spouse dies
2 Your spousersquos hours of employment are reduced
3 Your spousersquos employment ends for any reason other than his or her gross misconduct
4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or
5 You become divorced or legally separated from your spouse
Continuation Coverage Rights Under Cobra
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens
1 The parent-employee dies
2 The parent-employeersquos hours of employment are reduced
3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct
4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)
5 The parents become divorced or legally separated or
6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo
Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan
When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event
You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to
Asante Health System
How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended
Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov
If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)
Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator
Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Updated 91418 ND
PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is
eligible for coverage please contact us so that we can provide them with this notice
Important Notice from Asante 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 prescription drug coverage with Asante and about your options under Medicarersquos 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 Medicarersquos
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 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante 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
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan
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 Asante and donrsquot 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
Page 2
If you go 63 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 19 months without 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 Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll 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 Asante changes You also may request a copy of this notice at any time
If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by
Medicare in the next 12 months this notice doesnrsquot apply to you
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 ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos
how to get more information about Medicare prescription drug plans
Visit wwwmedicaregov
Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)
Remember Keep this 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)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A General Information
What is the Health Insurance Marketplace
Can I Save Money on my Health Insurance Premiums in the Marketplace
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace
How Can I Get More Information
Form Approved OMB No 1210-0149
5 31 2020
P AR T B Information About Health C overage O ffered by Y our E mployer
3 Employer name 4 Employer Identification Number (EIN)
5 Employer address 6 Employer phone number
7 City 8 State 9 ZIP code
10 Who can we contact about employee health coverage at this job
11 Phone number (if different from above) 12 Email address
Eligible Dependents include Your Legal Spouse or you or your spousersquos children under the age of 26 including biological child legally adopted child or child place with you for adoption current stepchild legally placed foster child child for whom you have legal guardianship child you are required to provide coverage for due to a court or administrative order as part of a QMCSO or NMSN or disabled child over the age of 26
Plan information including employee costs for 2020 medical plans can be found on myHR (httpshrasanteorg) or upon request to Human Resources
WHERE TO GET HELPKeep this contact information in case you have questions as you use your benefits throughout the year
Contact Phone number E-mail or website
Asante Absence Management and Workers Compensation
(541) 789-5395 ndash Medford(541) 472-7374 ndash Grants Pass(541) 789-5417 ndash Ashland
leavesasanteorg
Asante Benefits Helpline (541) 789-4551 myasantebenefitsasanteorgAsk HR
Asante Employee Health (541) 789-5008 ndash Medford(541) 472-7376 ndash Grants Pass(541) 201-4484 ndash Ashland
wwwasanteorg
Asante Human Resources (541) 789-4243 ndashMedfordAshland(541) 472-7382 ndash Grants Pass
wwwasanteorgemployee-benefits
Asante Recruitment (541) 789-4757 AsanteEmploymentasanteorg
HealthEquity mdash Flexible Spending Accounts Health Reimbursement Arrangements Health Savings Accounts
(866) 960-8055 wwwmyhealthequitycom
Hyatt Legal Plan (MetLaw) (800) 821-6400 wwwlegalplanscomAccess code MetLaw
Livongo (800) 945-4355
MercyFlights (800) 903-9000 wwwmercyflightscom
MetLife Dental (800) 942-0854 wwwmetlifecommybenefits
myStrength customerservicemystrengthcom
Regence - Advice24 (800) 267-6729 wwwregencecom
Regence - BabyWise (888) 569-2229 wwwregencecom
Regence - Case Management (866) 543-5765 wwwregencecom
Regence - Customer Service - Medical Claims Eligibility Precertification
(888) 344-8235 wwwregencecom
Regence - Employee Assistance Program
(866) 750-1327 wwwmyRBHcom
Regence - Health Coach (800) 856-8543 wwwregencecom
Regence - Pharmacy Services (844) 765-2894 wwwregencecom
The Standard (833) 760-7012 wwwstandardcom
Contact Phone number E-mail or website
The Standard Voluntary Benefits
General Questions (866) 851-2429Claims (866) 851-5505
wwwstandardcom
Asante Retirement Plan (800) 343-0860 NetBenefitscomAtWork
Vision Service Plan (VSP) (800) 877-7195 wwwvspcom
Willamette Dental (855) 433-6825 wwwwillamettedentalcom
REG-115823-1609-2017copy 201 Regence BlueCross BlueShield of Oregon
- 520
-
- 2020_Asante SBC_ Asante PPO Health Plan v2pdf
-
- 012020 Classic $500 $3500 857060 $25 Asante PPO Health Plan SBC
- 2017_01_01 Phase II_NoticeNDMA_Regence
-
- 2020_Asante SBC_Asante Reimbursement Health Plan v2pdf
-
- 012020 Classic $1500 $3500 907060 $25 Asante Reimbursement Health Plan SBC
- 2017_01_01 Phase II_NoticeNDMA_Regence
-
- 2020_Asante SBC_Asante Savings Health Plan v2pdf
-
- 012020 HSA 30 $1400 $2000 7050 Asante Savings Health Plan SBC
- 2017_01_01 Phase II_NoticeNDMA_Regence
-
- 2020_Asante SBC_AFWHP v2pdf
-
- 012019 HSA 30 $1400 $2000 7050 AFWHP SBC
- 2017_01_01 Phase II_NoticeNDMA_Regence
-