2025-2026
EMPLOYEE BENEFITS
MEDICAL | DENTAL | VISION
WELCOME
We are pleased to offer you a comprehensive benefits package intended to protect your well-being and financial health. This guide is your opportunity to learn more about all of the benefits available to you and your eligible dependents beginning July 1, 2025
To get the best value from your health care plan, please take the time to evaluate your coverage options and determine which plans best meet your health care and financial needs. By being a wise consumer, you can support your health and maximize your health care dollars.
Each year during Open Enrollment, you have the opportunity to make changes to your benefit plans. The enrollment decisions you make this year will remain in effect through June 30, 2026. You may make changes to your benefit elections only when you have a Qualifying Life Event. After such an event, you can make changes to your health care coverage within 30 days; otherwise, you cannot make changes to your benefits coverage until the next Open Enrollment period.
Availability of Summary Health Information
A Summary of Benefits and Coverage (SBC) summarizes important information about your health coverage in a standard format. The SBC is available on the web at www.benefitsinhand.com. The company identifier is gFurniture.
ELIGIBILITY
You are eligible for benefits if you are a regular, full-time employee working an average of 30 hours per week. Your coverage is effective on the first day of the month following 60 days of employment. You may also enroll eligible dependents for benefits coverage. The cost to you for dependent coverage will vary depending on the number of dependents you enroll and the particular plans you choose. When covering dependents, you must select the same plans for your dependents as you select for yourself.
Eligible Dependents Include
Your legal spouse or domestic partner
Children under the age of 26, regardless of student, dependency, or marital status
Children over the age of 26 who are fully dependent on you for support due to a mental or physical disability and who are indicated as such on your federal tax return
Qualifying Life Events
Your benefit elections remain in effect for the entire plan year until the following Open Enrollment. You may only change coverage during the plan year if you have a Qualifying Life Event such as marriage, divorce, birth or adoption, loss of other coverage, etc. You must notify Human Resources within 30 days if any of these events occur. Please contact Human Resources for a full list of Qualifying Events and the notification timeframes required for requested changes.
ONLINE ENROLLMENT INSTRUCTIONS
Go to www.benefitsinhand.com. First-time users follow steps 1-4. Returning users log in and start at step 5.
1. If this is your first time to log in, click on the New User Registration link. Once you register, you will use your username and password to log in.
2. Enter your personal information and company identifier of gFurniture and click Next
3. Create a username (work email address recommended) and password, then check the “I agree to terms and conditions” before you click Finish
4. If you used an email address as your username, you will receive a validation email to that address. You may now log in to the system.
5. Click the Start Enrollment button to begin the enrollment process.
6. Confirm or update your personal information and click Save & Continue
7. Edit dependents or add dependents that need to be covered on your benefits. Once all dependents are listed click Save & Continue
8. Follow the steps on the screen for each benefit to make your selection. Please notice there is an option to Decline Coverage. If you want to decline, click the Don’t want this benefit? button and select the reason you are declining.
9. Once you have elected or declined all benefits, you will see a summary of your selections. Click the Click to Sign button. Your enrollment will not be complete until you click the Click to Sign button.
EMPLOYEE RESPONSE CENTER
Have questions about your benefits or need help enrolling? The Higginbotham Employee Response Center can assist you with:
Call 866-419-3518 to speak with a representative Monday through Friday from 7:00 a.m. to 6:00 p.m. CT. If you leave a voicemail message after 3:00 p.m. CT, your call will be returned the next business day. You can also email questions or requests to helpline@higginbotham.net . Bilingual representatives are available.
MEDICAL COVERAGE
Our medical plan, provided by Blue Cross Blue Shield of Texas (BCBSTX) , includes access to both in-network and out-of-network providers using the BlueChoice PPO network. You will get better discounts and pay less money by remaining in-network. If you use outof-network providers, you will pay more for services. All out-of-network services are subject to Reasonable and Customary (R&C) limitations. This means you are responsible for all charges over this allowance.
To verify if your physician/hospital participates in the BCBSTX network, log on to www.bcbstx.com
PRESCRIPTION DRUG COVERAGE
Your BCBSTX medical plan includes prescription drug coverage. To save money on long-term or maintenance prescriptions, use the Express Scripts mail order or Accredo specialty drug programs.
Mail Order Prescriptions
Express Scripts delivers your long-term (maintenance) medicines to the address of your choice. Mail order requests may be made in the following ways:
New Prescriptions
Mail your prescription to Express Scripts or have your doctor fax or e-prescribe your order.
Ask your doctor to write a prescription for a 90-day supply of each of your long-term medicines. Or, ask your doctor to fax or e-prescribe your order.
To print a new prescription order form, go to www.express-scripts.com/rx to print a new prescription order form.
Mail your prescription, completed form, and payment to Express Scripts.
Medicines take about five days to deliver after receipt of your order.
Refill or Transfer Prescriptions
Online – Visit www.express-scripts.com/rx to register and create a profile. Log in to www.myprime.com and follow the links to Express Scripts Pharmacy.
Phone – Call 833-715-0942 and have your member ID card and your doctor’s and Rx information ready.
Mail – Visit www.bcbstx.com and log in to Blue Access for Members. Complete the mail order form and send it with your Rx and payment to Express Scripts.
Doctor – Ask your doctor to fax, call, or email your Rx to Express Scripts for you.
Questions? – Visit www.bcbstx.com or call the number on your member ID card.
Specialty Medications
If you need specialty drugs to treat complex or chronic conditions, use Accredo for new or transfer orders. Call 833-721-1619 to speak to a representative and place your order. Certain exclusions and limitations apply so visit www.accredo.com for details.
Prescription Drug Lists
Your prescription drug benefit plan is based on the BCBSTX drug list and has many levels of coverage, called tiers. Each tier has its own cost. As a rule, your copay/ coinsurance amount will be less for covered drugs in the lower tier (e.g., the cost for preferred brand drugs is often lower than for non-preferred brand drugs). Prescription drugs can be expensive so know your options.
How much you may pay for a drug will be based on your plan benefits and what tier the drug is on your drug list.
Consider using generic drugs, which are safe and work just as well as brand drugs. Generic drugs often cost less and may be substituted for a brand drug.
If available for your prescribed drug, use the mail order pharmacy program for a larger supply at a reduced cost.
Drugs that require a health care provider (e.g., a hospital or doctor’s office) to give them to you may be covered under your medical benefits instead of your pharmacy benefits. These drugs are not on the drug list.
Some drugs on the drug list may have additional requirements or extra steps to take before getting your prescription filled. Some may have dispensing limits, which means you may only be able to get a certain amount of your drug at one time.
Learn More
To find out what you will pay, log in to your Blue Access for Members account at www.bcbstx.com or call BCBSTX.
To know if your drug is on the list and what it will cost, search the full drug list at www.bcbstx.com/member/ prescription-drug-plan-information/drug-lists or call BCBSTX.
To see the full and current BCBSTX prescription drug lists, go to www.bcbstx.com/member/prescriptiondrug-plan-information/drug-lists
To ask questions about prescription drugs, call 800-521-2227 or visit www.bcbstx.com
Call the number on the back of your BCBSTX Member ID card to talk to registered nurses who can answer general health questions, make doctor appointments and advise where to go for care.
Access an audio library of more than 1,000 health-related topics in English and Spanish. It is free!
TELEMEDICINE
Your medical coverage offers telemedicine services through MDLIVE . Connect anytime day or night with a board-certified doctor via your mobile device or computer for the same cost as a visit to your regular physician.
When to Use MDLIVE
While telemedicine does not replace your primary care physician, it is a convenient and cost-effective option when you need care and:
Have a non-emergency issue and are considering an after hours health care clinic, urgent care clinic, or emergency room for treatment
Are on a business trip, vacation, or away from home
Are unable to see your primary care physician
Use telehealth services for minor conditions such as:
Sore throat
Headache
Stomachache
Cold
Flu
Allergies
Fever
Urinary tract infections
Virtual Visits with licensed behavioral health therapists are available by appointment. Get virtual care for:
Anxiety
Depression
Stress management
And more
Do not use telemedicine for serious or life-threatening emergencies.
Registration is Easy
Register with MDLIVE so you are ready to use this valuable service when and where you need it.
Visit www.mdlive.com/bcbstx
Call 888-680-8646
Text BCBSTX to 635-483 to download the mobile app
Nurseline
HEALTH CARE OPTIONS
Becoming familiar with your options for medical care can save you time and money.
Non-Emergency Care
Telehealth
Access to care via phone, online video, or mobile app whether you are home, work, or traveling; medications can be prescribed. 24 hours a day, 7 days a week.
Doctor’s Office
Generally, the best place for routine preventive care; established relationship; able to treat based on medical history. Office hours vary.
Retail Clinic
Usually lower out-of-pocket cost than urgent care; when you can’t see your doctor; located in stores and pharmacies. Hours vary based on store hours.
Urgent Care
When you need immediate attention; walk-in basis is usually accepted. Generally includes evening, weekend, and holiday hours.
Emergency Care
Hospital ER
Life-threatening or critical conditions; trauma treatment ; multiple bills for doctor and facility. 24 hours a day, 7 days a week
Freestanding ER
Services do not include trauma care; can look similar to an urgent care center, but medical bills may be 10 times higher. 24 hours a day, 7 days a week.
Allergies
Cough/cold/flu Rash
Stomachache
Infections
Sore and strep throat
Vaccinations
Minor injuries/sprains/strains
Common infections
Minor injuries
Pregnancy tests
2-5 minutes
15-20 minutes
Vaccinations $ 15 minutes
Sprains and strains
Minor broken bones
Small cuts that may require stitches
Minor burns and infections
Chest pain
Difficulty breathing
Severe bleeding
Blurred or sudden loss of vision
Major broken bones
Most major injuries except trauma
Severe pain
minutes
$$$$ 4+ hours
varies
Note: Examples of symptoms are not inclusive of all health issues. Wait times described are only estimates. This information is not intended as medical advice. If you have questions, please call the phone number on the back of your medical ID card.
BCBSTX RESOURCES
Blue Access for Members
Blue Access for Members (BAM) is the secure BCBSTX member website where you can:
Check claim status or history
Confirm dependent eligibility
Print Explanation of Benefits (EOB) forms
Locate in-network providers
Print or request an ID card Log on to www.bcbstx.com to register.
Mobile App
The BCBSTX mobile app can help you stay organized and in control of your health anytime, anywhere. Log in from your mobile device to access your BAM account, including:
Track account balances and deductibles
Access ID card information
Find doctors, dentists, and pharmacies
Text BCBSTX to 33633 to download the app.
Member Rewards
Register for Member Rewards and receive rewards for making good health care decisions, such as seeking care from preferred providers. Log in to BAM and click on the Doctors & Hospitals tab under Provider Finder.
Blue365
Blue365 can help you save money on health and wellness products and services not covered by insurance. There are no claims to file, and you do not need a referral or preauthorization. Sign up for Blue365 at www.blue365deals.com/bcbstx to receive weekly Featured Deals by email.
Well onTarget
Well onTarget provides the support you need to make healthy choices. Access personalized tools and resources on the secure Well onTarget website, including:
Self-management programs
Health resources and information
Tools and Trackers
Health assessments
Visit www.wellontarget.com to access the Well onTarget member portal. If you have already registered on BAM, you will use the same login information. If not, you can register on this site. Customer Service is available at 877-806-9380
Digital Mental Health
Many people struggle with a mental health concern at some point in their lives. When you learn new skills, it can help break old patterns that may be holding you back. Digital mental health programs from Learn to Live can help you get your mental health on track so you can feel better and enjoy life more. Check out the available programs included at no extra cost by logging into www. bcbstx.com, clicking Wellness and then Digital Mental Health or, tap Digital Mental Health in the BCBSTX App. You can also register a minor (must be 13 to 17 years old).
Employee Assistance Program
There may be a time when you need a little extra support through job stress, grief, legal or financial issues, or other life challenges. Your Employee Assistance Program has options for you at no added cost. Talk one-on-one with a counselor or use online resources. Learn more at www.guidanceresources. com, using Web ID BCBSTXEAP.
Hinge Health
If you suffer from constant back and joint pain, Hinge Health can help without drugs or surgery. Get personal therapy, unlimited support, a computer tablet, and wearable sensors — all for free! Average results show 60% pain reduction and two out of three surgeries avoided. Doctors and physical therapists created this program for long-term results. Your remote care may be done in the comfort of your own home. You will begin with a 12-week intensive phase, followed by an ongoing program that builds on what you have learned.
To be eligible for this program, you must:
Be covered under a BCBSTX medical plan (includes spouse and children)
Be age 18+
Have a chronic musculoskeletal claim in the last three months
Be contacted by Hinge Health to sign up based on your medical claim; self-referrals will not be accepted
Learn more and apply at www.hingehealth.com/bcbstx
VirtualCheckup
BCBSTX partners with Catapult Health to bring VirtualCheckups right to you — for free! Instead of going to your doctor for a preventive checkup, you decide when and where to be tested using the VirtualCheckup Home Kit. This saves you time and money! Once the kit is mailed to you, all you need to do is follow the simple directions and complete your VirtualCheckup with a nurse practitioner. Learn more at www.virtualcheckup.com
Muscle and Joint Pain Care
Flex by Airrosti provides personalized care for muscle and joint pain (back or neck issues, carpal tunnel, plantar fasciitis, tension headaches, and more). Convenient inclinic and virtual care options are available to serve you. Airrosti provides:
Evaluation – A 10-15 minute complimentary evaluation with an Airrosti provider
Assessment – An expert assessment of your injury or any pain-related issues
Review – A review of findings and discussion of your treatment options
Personalized plan – Targeted exercises, recovery tools, and provider-guided treatment
Visit www.airrosti.com/flex or call 800-404-6050 to schedule a free virtual evaluation.
Free Glucose Meters
BCBSTX offers you a choice of certain Contour Next blood glucose meters to help manage diabetes. Visit www.contournext.com for details and ask your doctor which meter best fits your needs. To order a free meter, call 800-401-8440 and use ID code BDC-HCS
DENTAL COVERAGE
Good oral hygiene can contribute to your overall health. That is why it is more important than ever to get regular dental checkups. Club Westside offers two dental options under the BCBSTX Dental Network that help you pay for preventive, basic, major, and orthodontic care.
Finding an In-Network Dentist is Easy
For a list of in-network general and specialty dentists, go to www.bcbstx.com and use the Provider Finder tool by clicking on Find a Doctor or Hospital and then on Find a Dentist on the left side of the page. You can search for a dentist near your home, school, or office.
BlueCare Dental Connection
As an enhanced service, BCBSTX offers BlueCare Dental Connection. This service provides educational information and other resources to help you make choices about your dental care — at no extra cost. This includes 24/7 access to their online Dental Wellness Center to ask dental-related questions, find dentists, research fees, and view animations on dental topics. Register and log in to Blue Access for Members, click Dental under Quick Links and then on Dental Wellness Center.
Preventive Care
Exams, Cleanings, X-rays, Fluoride Treatments, Space Maintainers, Sealants
Basic Services
Fillings, Extractions, Oral Surgery, Endodontics, Periodontics, Emergency Exams
Major Procedures
Crowns, Inlays/Outlays, Dentures and Bridgework, Repairs
Children (up to 19th birthday)
1 Out-of-network providers are paid at the 90th percentile of Usual and Customary for their area. This typically results in a better reimbursement if you receive services from an out-of-network provider. You are responsible for any charges above the allowance.
2 Out-of-network providers are paid at a Maximum Allowable Charge (MAC) schedule. You are responsible for the difference between the billed charges and the MAC rate.
3 Calendar year is January 1 – December 31. Your calendar year deductible and out-of-pocket maximums will reset to $0 every January 1.
VISION PLAN
Club Westside’s vision plan is designed to provide basic eyewear needs and to help preserve your health and eyesight. Besides identifying eye problems, vision exams can help detect certain medical conditions such as diabetes or high cholesterol. To help you manage your health, we offer vision coverage through Guardian using the VSP Network. Under this plan, you may use the eye care professional of your choice. However, when you use a participating in-network provider, you receive higher levels of coverage. To find an in-network provider, go to www.vsp.com
LIFE AND AD&D INSURANCE
Life insurance is an important part of your financial security, especially if others depend on you for support. Even if you are single, your beneficiary can use your Life insurance to pay off your debts, such as credit cards, mortgages, and other final expenses.
Accidental Death & Dismemberment (AD&D) insurance helps protect you and your family from the unforeseen financial hardship of a serious accident that causes death or dismemberment. AD&D insurance provides specified benefits for a covered accidental bodily injury that directly causes dismemberment (i.e., the loss of a hand, foot, or eye). In the event that death occurs from an accident, 100% of the AD&D benefit would be payable to your beneficiaries.
Basic Life and AD&D
Basic Life insurance and AD&D insurance in the amounts of $20,000 are provided at no cost to you. Coverage is provided through Guardian
Designating a Beneficiary
Designating a beneficiary ensures to whom your Life and AD&D insurance benefits are paid in case of your death. You can name more than one beneficiary, and you can change beneficiaries at any time. If you name more than one beneficiary, identify the share for each. Be sure all names are correct when you designate your beneficiaries.
Voluntary Life and AD&D
Coverage is provided through Guardian. You may purchase additional Life and AD&D insurance for yourself and your eligible dependents. If you decline Voluntary Life and AD&D insurance when first eligible or if you elect coverage and wish to increase your benefit amount at a later date, Evidence of Insurability (EOI) — proof of good health — may be required before coverage is approved. You can find more information at www. guardiananytime.com/e01.
You must elect Voluntary Life and AD&D coverage for yourself in order to elect coverage for your spouse or children. If you leave Club Westside, you may take the insurance with you by paying premiums direct to the insurance company.
COVERAGE FOR COVERAGE AVAILABLE
Employee
Spouse
Child(ren) age 14 days to 26 years
Increments of $10,000 up to $500,000
Guaranteed Issue: $130,000
Increments of $5,000 up to $250,000 not to exceed 50% of Employee coverage
Guaranteed Issue: $25,000
Increments of $2,000 to a maximum of $10,000; children up to 6 months for $1,000.
Guaranteed Issue: $10,000
Voluntary Life and AD&D benefits are reduced by 35% at age 65 and by 50% at age 70 from the original amount.
Voluntary Life and AD&D Rates
How to Calculate Your Weekly Cost
Decide the amount of coverage you want to purchase.
Divide that amount by $1,000.
Multiply by your age appropriate rate listed in the above table.
Example: You are 46 years old and want to purchase $60,000 of coverage.
$60,000 ÷ $1,000 = 60 × $0.273 = $16.38 × 12 months = $196.56 ÷ 52 weeks = $3.78 per week
DISABILITY INSURANCE
A salary replacement plan is an important benefit for you and your family. Disability insurance provides partial income protection if you are unable to work due to a covered accident or illness. Disability coverage is provided through Guardian
Voluntary Short Term Disability Insurance
Even a few weeks away from work can make it difficult to manage household costs. Short Term Disability (STD) covers a portion of your salary in the event you are unable to work due to a pregnancy, injury, or illness so that you can focus on getter better and worry less about keeping up with your bills.
COVERAGE BENEFIT
How to Calculate Your Biweekly Cost
SUPPLEMENTAL INSURANCE
Critical Illness Insurance
Guardian’s Critical Illness insurance is specifically designed to help provide financial security upon diagnosis of a covered critical illness. You may purchase coverage for yourself and your family. The lump-sum benefit, paid directly to you, is paid in addition to any other coverage, and covers medical and non-medical costs associated with your illness. Covered illnesses are shown in the chart below.
CRITICAL ILLNESS PLAN
Accident Insurance
Accident insurance is offered through Guardian. For covered accidental injuries, fixed benefits are paid directly to you regardless of any other coverage you may have and you can spend it any way you choose. Benefits are paid according to a fixed schedule that includes benefits for hospitalization, fractures, dislocations, emergency room visits, major diagnostic exams, physical therapy, and more. Please refer to the benefit summary for details.
Provides
WELLNESS BENEFIT
EMPLOYEE ASSISTANCE PROGRAM
The Employee Assistance Program (EAP) from Guardian through the ComPsych GuidanceResources program helps you and family members cope with a variety of personal and work-related issues. This program provides confidential counseling and support services at little or no cost to you to help with:
Relationships
Work-life balance
Stress and anxiety
Will preparation and estate resolution
Visit www.guidancresources.com (Web ID: Guardian).
Call 855-239-0743
Download the GuidanceNow app
Grief and loss
Childcare and eldercare resources
Substance abuse
BENEFITS COST WORKSHEET
IMPORTANT NOTICES
Women’s Health and Cancer Rights Act of 1998
In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully.
As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following benefits:
All stages of reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
Prostheses and treatment of physical complications of the mastectomy, including lymphedema.
Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan.
Special Enrollment Rights
This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time.
Loss of Other Coverage or Becoming Eligible for Medicaid or a state Children’s Health Insurance Program (CHIP)
If you are declining coverage for yourself or your dependents because of other health insurance or group health plan coverage, you may be able to later 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 enroll within 31 days after your or your dependents’ other coverage ends (or after the employer that sponsors that coverage stops contributing toward the other coverage).
If you or your dependents lose eligibility under a Medicaid plan or CHIP, or if you or your dependents become eligible for a subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents in this plan. You must provide notification within 60 days after you or your dependent is terminated from, or determined to be eligible for, such assistance.
Marriage, Birth or Adoption
If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 31 days after the marriage, birth, or placement for adoption.
For More Information or Assistance
To request special enrollment or obtain more information, contact:
Club Westside
Human Resources
1200 S Wilcrest Drive Houston TX 77042
713-783-1620
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 Club Westside and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to enroll in a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
If neither you nor any of your covered dependents are eligible for or have Medicare, this notice does not apply to you or the dependents, as the case may be. However, you should still keep a copy of this notice in the event you or a dependent should qualify for coverage under Medicare in the future. Please note, however, that later notices might supersede this notice.
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that offers prescription drug coverage. All Medicare prescription 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. Club Westside has determined that the prescription drug coverage offered by the Club Westside medical plan is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered Creditable Coverage. The HSA plan is considered Creditable Coverage.
IMPORTANT NOTICES
Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare prescription drug plan, as long as you later enroll within specific time periods.
You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare. If you decide to wait to enroll in a Medicare prescription drug plan, you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15 through December 7 but as a general rule, if you delay your enrollment in Medicare Part D after first becoming eligible to enroll, you may have to pay a higher premium (a penalty).
You should compare your current coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have a copy, you can get one by contacting Club Westside at the phone number or address listed at the end of this section.
If you choose to enroll in a Medicare prescription drug plan and cancel your current Club Westside prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. To regain coverage, you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description to determine if and when you are allowed to add coverage.
If you cancel or lose your current coverage and do not have prescription drug coverage for 63 days or longer prior to enrolling in the Medicare prescription drug coverage, your monthly premium will be at least 1% per month greater for every month that you did not have coverage for as long as you have Medicare prescription drug coverage. For example, if nineteen months lapse without coverage, your premium will always be at least 19% higher than it would have been without the lapse in coverage.
For more information about this notice or your current prescription drug coverage:
Contact the Human Resources Department at 713-7831620.
NOTE: You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage and if this coverage changes. You may also request a copy.
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 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. For more information about Medicare prescription drug coverage:
Visit www.medicare.gov.
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 877-486-2048
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you can call them at 800772-1213. TTY users should call 800-325-0778.
Remember: Keep this Creditable Coverage notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, 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 whether or not you are required to pay a higher premium (a penalty).
July 1, 2025
Club Westside Human Resources 1200 S Wilcrest Drive Houston TX 77042 713-783-1620
Notice of HIPAA Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes numerous requirements on employer health plans concerning the use and disclosure of individual health information. This information known as protected health information (PHI), includes virtually all individually identifiable health information held by a health plan – whether received in writing, in an electronic medium or as oral communication. This notice describes the privacy practices of the Employee Benefits Plan (referred to in this notice as the Plan), sponsored by Club Westside, hereinafter referred to as the plan sponsor.
IMPORTANT NOTICES
The Plan is required by law to maintain the privacy of your health information and to provide you with this notice of the Plan’s legal duties and privacy practices with respect to your health information. It is important to note that these rules apply to the Plan, not the plan sponsor as an employer.
You have the right to inspect and copy protected health information which is maintained by and for the Plan for enrollment, payment, claims and case management. If you feel that protected health information about you is incorrect or incomplete, you may ask the Human Resources Department to amend the information. For a full copy of the Notice of Privacy Practices describing how protected health information about you may be used and disclosed and how you can get access to the information, contact the Human Resources Department.
Complaints: If you believe your privacy rights have been violated, you may complain to the Plan and to the Secretary of Health and Human Services. You will not be retaliated against for filing a complaint. To file a complaint, please contact the Privacy Officer.
Club Westside Human Resources
1200 S Wilcrest Drive Houston TX 77042
713-783-1620
Conclusion
PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations.
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www. askebsa.dol.gov or call 1-866-444-EBSA (3272)
If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, 2026. Contact your State for more information on eligibility.
TEXAS – MEDICAID
Website: https://www.hhs.texas.gov/services/financial/ health-insurance-premium-payment-hipp-program Phone: 1-800-440-0493
To see if any other States have added a premium assistance program since January 31, 2026 , or for more information on special enrollment rights, you can contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
Continuation of Coverage Rights Under COBRA
Under the Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), if you are covered under the Club Westside group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the Club Westside plan after you have left employment with the company. If you wish to elect COBRA coverage, contact your Human Resources Department for the applicable deadlines to elect coverage and pay the initial premium.
IMPORTANT NOTICES
Club Westside Human Resources
1200 S Wilcrest Drive Houston TX 77042
713-783-1620
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-ofnetwork providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Certain services at an in-network hospital or ambulatory surgical center – When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections. You are never required to give up your protections from balance billing. You also are not required to get care outof-network. You can choose a provider or facility in your plan’s network.
When balance billing is not allowed, you also have the following protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay outof-network providers and facilities directly.
Your health plan generally must:
Cover emergency services without requiring you to get approval for services in advance (prior authorization).
Cover emergency services by out-of-network providers.
Base what you owe the provider or facility (costsharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you have been wrongly billed, you may contact your insurance provider. Visit www.cms.gov/ nosurprises for more information about your rights under federal law.
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information
Even if you are offered health coverage through your employment, you may have other coverage options through the Health Insurance Marketplace (“Marketplace”). To assist you as you evaluate options for you and your family, this notice provides some basic
IMPORTANT NOTICES
information about the Health Insurance Marketplace.
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 in your geographic area.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer does not offer coverage, or offers coverage that is not considered affordable for you and doesn’t meet certain minimum value standards (discussed below). The savings on your premium that you’re eligible for depends on your household income. You may also be eligible for a tax credit that lowers your costs.
Does Employment-Based Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that is considered affordable for you and meets certain minimum value standards, you will not be eligible for a tax credit, or advance payment of the tax credit, for your Marketplace coverage and may wish to enroll in your employment-based health plan. However, you may be eligible for a tax credit, and advance payments of the 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 is considered affordable for you or meet minimum value standards. If your share of the premium cost of all plans offered to you through your employment is more than 9.12%1 of your annual household income, or if the coverage through your employment does not meet the “minimum value” standard set by the Affordable Care Act, you may be eligible for a tax credit, and advance payment of the credit, if you do not enroll in the employmentbased health coverage. For family members of the employee, coverage is considered affordable if the employee’s cost of premiums for the lowest-cost plan that would cover all family members does not exceed 9.12% of the employee’s household income.1, 2
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered through your employment, then you may lose access to whatever the employer contributes to the employmentbased coverage. Also, this employer contribution -as well as your employee contribution to employmentbased coverage- is generally excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. In addition, note that if the health
coverage offered through your employment does not meet the affordability or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You should consider all of these factors in determining whether to purchase a health plan through the Marketplace.
When Can I Enroll in Health Insurance Coverage through the Marketplace?
You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period. Open Enrollment varies by state but generally starts November 1 and continues through at least December 15.
Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment Period. In general, you qualify for a Special Enrollment Period if you’ve had certain qualifying life events, such as getting married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the qualifying life event to enroll in a Marketplace plan.
There is also a Marketplace Special Enrollment Period for individuals and their families who lose eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage on or after March 31, 2023, through July 31, 2024. Since the onset of the nationwide COVID-19 public health emergency, state Medicaid and CHIP agencies generally have not terminated the enrollment of any Medicaid or CHIP beneficiary who was enrolled on or after March 18, 2020, through March 31, 2023. As state Medicaid and CHIP agencies resume regular eligibility and enrollment practices, many individuals may no longer be eligible for Medicaid or CHIP coverage starting as early as March 31, 2023. The U.S. Department of Health and Human Services is offering a temporary Marketplace Special Enrollment period to allow these individuals to enroll in Marketplace coverage.
Marketplace-eligible individuals who live in states served by HealthCare.gov and either- submit a new application or update an existing application on HealthCare.gov between March 31, 2023 and July 31, 2024, and attest to a termination date of Medicaid or CHIP coverage within the same time period, are eligible for a 60-day Special Enrollment Period. That means that if you lose Medicaid or CHIP coverage between March 31, 2023, and July 31, 2024, you may be able to enroll in Marketplace coverage within 60 days of when you lost Medicaid or CHIP
IMPORTANT NOTICES
coverage. In addition, if you or your family members are enrolled in Medicaid or CHIP coverage, it is important to make sure that your contact information is up to date to make sure you get any information about changes to your eligibility. To learn more, visit www.HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325
What about Alternatives to Marketplace Health Insurance Coverage?
If you or your family are eligible for coverage in an employment-based health plan (such as an employersponsored health plan), you or your family may also be eligible for a Special Enrollment Period to enroll in that health plan in certain circumstances, including if you or your dependents were enrolled in Medicaid or CHIP coverage and lost that coverage. Generally, you have 60 days after the loss of Medicaid or CHIP coverage to enroll in an employment-based health plan, but if you and your family lost eligibility for Medicaid or CHIP coverage between March 31, 2023 and July 10, 2023, you can request this special enrollment in the employment-based health plan through September 8, 2023. Confirm the deadline with your employer or your employment-based health plan.
Alternatively, you can enroll in Medicaid or CHIP coverage at any time by filling out an application through the Marketplace or applying directly through your state Medicaid agency. Visit https://www. healthcare.gov/medicaid-chip/getting-medicaidchip/ for more details.
How Can I Get More Information?
For more information about your coverage offered through your employment, please check your health plan’s summary plan description or contact Human Resources.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit www.HealthCare. gov for more information, including an online application
for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
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: Club Westside
5. Employer Address: 1200 S Wilcrest Dr
7. City: Houston
4. Employer Identification Number (EIN): 74-2177645
6. Employer Phone Number: 713-783-1620
8. State: TX 9. ZIP Code: 77042
10. Who can we contact at this job?: Elliott McCullough
11. Phone Number (if different from above): 713-783-1620
12. E-Mail Address: elliott@clubwestside.com
As your employer, we offer a health plan to all eligible employees (see the Eligibility section of this guide). 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 Indexed annually; see https://www.irs.gov/pub/irs-drop/rp-22-34.pdf for 2023.
2 An employer-sponsored or other employment-based 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 percent of such costs. For purposes of eligibility for the premium tax credit, to meet the “minimum value standard,” the health plan must also provide substantial coverage of both inpatient hospital services and physician services.
This brochure highlights the main features of Club Westside. It does not include all plan rules, details, limitations and exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents, the plan documents are the final authority. Club Westside reserves the right to change or discontinue its employee benefits plans at anytime.