2025-2026
EMPLOYEE BENEFITS BOOK
IMPORTANT CONTACTS
Benitez, Account Coordinator 832-478-1952 vbenitez@higginbotham.net
WELCOME
We are pleased to offer a full benefits package to help protect your well-being and financial health. Read this guide to learn about the benefits available to you and your eligible dependents starting October 1, 2025.
Each year during Open Enrollment, you may make changes to your benefit plans. The benefit choices you make this year will remain in effect through September 30, 2026. Take time to review these benefit options and select the plans that best meet your needs. After Open Enrollment, you may only make changes to your benefit elections if you have a Qualifying Life Event.
Availability of Summary Health Information
Your benefits program offers three medical plan coverage options. To help you make an informed choice and compare your options, a Summary of Benefits and Coverage is available on the web at www.bcbstx.com or by calling 800-521-2227
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices for your prescription drug coverage. Please see page 24 for more details.
ELIGIBILITY
You are eligible for benefits if you are a regular, full-time employee working an average of 30 hours per week and completing 30 consecutive days of employment. Your coverage is effective on the first of the month after 30 days. You may also enroll eligible dependents for benefits coverage. The cost for coverage depends on the number of dependents you enroll and the benefits you choose. When covering dependents, you must select and be on the same plans.
Eligible Dependents
z Your legal spouse
z Children under the age of 26 regardless of student, dependency, or marital status
z 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
Once you elect your benefit options, they 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:
• Marriage, legal separation, or annulment
• Birth, adoption, or placement for adoption of an eligible child
• Change in your spouse’s employment status that affects benefits eligibility
• Significant change in benefit plan coverage for you, your spouse, or your child
• FMLA event, COBRA event, judgment, or decree
• Receiving a Qualified Medical Child Support Order
• Death of your spouse or child
• Divorce
• Change in your child’s eligibility for benefits (reaching age 26)
• Becoming eligible for Medicare, Medicaid/CHIP, or TRICARE
If you have a Qualifying Life Event and want to change your elections, you must notify Human Resources and complete your changes within 30 or 60 days of the event You may be asked to provide documentation to support the change. Contact Human Resources for specific details.
Employee Response Center
Employee benefits can be complicated. The Higginbotham Employee Response Center (ERC) can assist you with the following:
• Enrollment
• Benefits information
• Claims or billing questions
• Eligibility issues
Call or text 866-419-3518 to speak with a bilingual representative Monday through Friday from 7:00 a.m. to 6:00 p.m. CT. If you leave a message after 3:00 p.m. CT, your call or text will be returned the next business day. You can also email questions or requests to helpline@higginbotham.net Bilingual representatives are available.
HOW TO ENROLL
Online Enrollment Instructions
Go to www.benefitsinhand.com to begin the enrollment process. 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 SamsonControls and click Next
3. Create a username (work email address recommended) and password, then check the I agree to terms and conditions box 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 or add dependents who 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 wish to decline, click the Don’t want this benefit? button and select the reason for 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. Have questions about your benefits or need help enrolling? Call the ERC at 866-419-3518. Benefits experts are available to take your call Monday through Friday, 7:00 a.m. – 6:00 p.m. CT.
MEDICAL COVERAGE
Find a Network Provider
Visit www.bcbstx.com or call 800-521-2227
Reminder:
You may only purchase insurance through the Marketplace if you experience a Qualifying Life Event OR during Open Enrollment. The Federal Marketplace Open Enrollment dates are November 1 through December 15.
The medical plan options through Blue Cross and Blue Shield of Texas (BCBSTX) protect you and your family from major financial hardship in the event of illness or injury. You have a choice of two plans:
z Base Plan – This plan has a $4,000 individual and $8,000 family in-network deductible
z Buy-Up Plan – This plan has a $2,500 individual and a $7,500 family in-network deductible
Preferred Provider Organization
A Preferred Provider Organization (PPO) allows you to see any provider when you need care. When you see in-network providers for care, you will pay less and get the highest level of benefits. You will pay more for care if you use out-of-network providers. When you see in-network providers, your office visits, urgent care visits, and prescription drugs are covered with a copay and most other in-network services are covered at the coinsurance level.
High Deductible Health Plan
A High Deductible Health Plan (HDHP) also allows you to see any provider when you need care, but you will pay less for care when you go to in-network providers. In exchange for a lower per-paycheck cost for medical benefits, you must satisfy a higher plan deductible that applies to almost all health care expenses, including prescription drugs. If you enroll in the HDHP, you may be eligible to open a Health Savings Account (HSA) (see page 11).
Health Coverage Reminder
The Patient Protection and Affordable Care Act (PPACA) requires most individuals to have minimum essential health coverage. You may obtain coverage through your employer or through the Marketplace.
Depending on your income and the coverage offered by your employer, you may be able to obtain lower cost private insurance in the Marketplace. If you buy insurance through the Marketplace, you may lose any employer contribution to your health benefits.
Visit www.HealthCare.gov for Marketplace information.
MEDICAL SUMMARY
BCBSTX RESOURCES
Blue Access for Members
Blue Access for Members (BAM) is the secure BCBSTX member website where you can:
z Check claim status or history
z Confirm dependent eligibility
z Print Explanation of Benefits (EOB) forms
z Locate in-network providers
z Print or request an ID card
To get started, log on to www.bcbstx.com and use the information on your BCBSTX ID card to complete the registration process.
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:
z Track account balances and deductibles
z Access ID card information
z Find doctors, dentists, and pharmacies
Text BCBSTXAPP to 33633 or search your mobile device’s app store to download.
Nurseline
Call 800-581-0368 for immediate access to registered nurses who can answer general health questions, make appointments with your doctor, and help determine where to go for immediate or emergency health care services. You can also access an audio library of more than 1,000 health-related topics in both English and Spanish.
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 about the same cost as a visit to your regular physician.
While telemedicine does not replace your primary care physician, it is a convenient and cost-effective option when you need care.
WHEN TO USE TELEMEDICINE
Conditions Treated Include
z Sore throat
z Headache
z Stomachache
z Cold
Allergies
Fever (age 3+)
Do not use telemedicine for serious or life-threatening emergencies.
HEALTH CARE OPTIONS
Becoming familiar with your options for medical care can save you time and money.
NON - EMERGENCY CARE
Access to care via phone, online video or mobile app whether you are home, work or traveling; medications can be prescribed
VIRTUAL VISITS/ TELEMEDICINE
DOCTOR’S OFFICE
RETAIL CLINIC
24 hours a day, 7 days a week
Generally, the best place for routine preventive care; established relationship; able to treat based on medical history
Office hours vary
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
When you need immediate attention; walk-in basis is usually accepted
URGENT CARE
Generally includes evening, weekend and holiday hours
EMERGENCY CARE
Life-threatening or critical conditions; trauma treatment; multiple bills for doctor and facility
24 hours a day, 7 days a week
HOSPITAL ER
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 and strains
• Common infections
• Minor injuries
• Pregnancy tests
• Vaccinations
• 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
15-20 minutes
15 minutes
Minimal
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.
HEALTH SAVINGS ACCOUNT
An HSA is more than a way to help you and your family cover current medical costs — it is also a tax-exempt tool to supplement your retirement savings and to cover future health costs.
As a type of personal savings account that is always yours even if you change health plans or jobs, the money in your HSA (including interest and investment earnings) grows tax-free and spends tax-free if used to pay for current or future qualified medical expenses. There is no “use it or lose it” rule — you do not lose your money if you do not spend it in the calendar year — and there are no vesting requirements or forfeiture provisions. The account automatically rolls over year after year.
HSA Eligibility
You are eligible to open and contribute to an HSA if you are:
z Enrolled in an HSA-eligible HDHP (our BCBSTX HDHP)
z Not covered by another plan that is not a qualified HDHP, such as your spouse’s health plan
z Not enrolled in a Health Care Flexible Spending Account
z Not eligible to be claimed as a dependent on someone else’s tax return
z Not enrolled in Medicare, Medicaid, or TRICARE
z Not receiving Veterans Administration benefits
You can also use HSA funds to pay health care expenses for your dependents, even if they are not covered by the HDHP. You decide whether to use the money in your account to pay for qualified expenses or let it grow for future use.
Maximum Contributions
Your HSA contributions may not exceed the annual maximum amount established by the IRS. The annual contribution maximum is based on the coverage option you elect:
2025
• Individual – $4,300
• Family – $8,550
2026
• Individual – $4,400
• Family – $8,750
If you are age 55 or older, you may make a yearly catch-up contribution of up to $1,000 to your HSA. If you turn 55 at any time during the plan year, you are eligible to make the catch-up contribution for the entire plan year.
Opening an HSA
If you meet the eligibility requirements, you may open an HSA administered by HSA Bank . You will receive a debit card to manage your HSA account reimbursements. Keep in mind, available funds are limited to the balance in your HSA. To open an account, go to www.hsabank.com
Important HSA Information
• Always ask your network doctor to file claims with your medical, dental, or vision carrier so you will get the highest level of benefits. You can pay the doctor with your HSA debit card for any balance due.
• You, not your employer, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit.
• You may open an HSA at the financial institution of your choice, but only accounts opened through HSA Bank are eligible for automatic payroll deduction.
Important
Samson Controls will be contributing $500 annually to members enrolled in the HDHP MTBCP60722 plan. $250 will be contributed 10/1/2025 and $250 will be contributed 4/1/2026.
FLEXIBLE SPENDING ACCOUNTS
HOW THE HEALTH CARE FSA WORKS
You can access the funds in your Health Care FSA two ways:
z Use your Higginbotham Benefits Debit Card to pay for qualified expenses, doctor visits, and prescription copays.
z Pay out-of-pocket and submit your receipts for reimbursement:
Fax – 866-419-3516
Email – flexclaims@ higginbotham.net
App – Higginbotham
Online – https://flexservices. higginbotham.net
Please refer to IRS Publication
502 Medical and Dental Expenses at www.irs.gov for a complete description of eligible medical and dental expenses.
A Flexible Spending Account (FSA) allows you to set aside pretax dollars from each paycheck to pay for certain IRS-approved health and dependent care expenses. We offer a health care and a dependent care FSA, which are administered by Higginbotham
Health Care FSA
The Health Care FSA covers qualified medical, dental, and vision expenses for you or your eligible dependents. You may contribute up to $3,300 annually to a Health Care FSA and you are entitled to the full election from day one of your plan year. Eligible expenses include:
z Dental and vision expenses
z Medical deductibles and coinsurance
z Prescription copays
z Hearing aids and batteries
You may not contribute to a Health Care FSA if you enrolled in a High Deductible Health Plan (HDHP) and contribute to an HSA.
HIGGINBOTHAM BENEFITS DEBIT CARD
The Higginbotham Benefits Debit Card gives you immediate access to funds in your Health Care FSA when you make a purchase without needing to file a claim for reimbursement. If you use the debit card to pay anything other than a copay amount, you will need to submit an itemized receipt or an EOB. If you do not submit your receipts, you will receive a request for substantiation. You will have 60 days to submit your receipts after receiving the request for substantiation before your debit card is suspended. Check the expiration date on your card to see when you should order a replacement card(s).
Dependent Care FSA
The Dependent Care FSA helps pay for expenses associated with caring for elder or child dependents so you or your spouse can work or attend school full time. You can use the account to pay for daycare or babysitter expenses for your children under age 13 and qualifying older dependents, such as dependent parents. Reimbursement from your Dependent Care FSA is limited to the total amount deposited in your account at that time. To be eligible, you (and your spouse, if married) must be gainfully employed, looking for work, a full-time student, or incapable of self-care.
DEPENDENT CARE FSA CONSIDERATIONS
z Overnight camps are not eligible for reimbursement (only day camps can be considered).
z If your child turns 13 midyear, you may only request reimbursement for the part of the year when the child is under age 13.
z You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care.
z The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.
Important FSA Rules
z The maximum per plan year you can contribute to a Health Care FSA is $3,300. The maximum per plan year you can contribute to a Dependent Care FSA is $7,500 when filing jointly or head of household and $3,750 when married filing separately.
z You cannot change your election during the year unless you experience a Qualifying Life Event.
z You can continue to file claims incurred during the plan year for another 30 days (up until January 31, 2025).
z Your Health Care FSA debit card can be used for health care expenses only. It cannot be used to pay for dependent care expenses.
z The IRS has amended the “use it or lose it” rule to allow you to carry over up to $660 in your Health Care FSA into the next plan year. The carry-over rule does not apply to your Dependent Care FSA.
DENTAL COVERAGE
Find an In-Network Dentist
Visit www.mutualofomaha.com or call 833-561-1688.
Our dental plans help you maintain good oral health through affordable options for preventive care, including regular checkups and other dental work. Coverage is provided through Mutual of Omaha .
DPPO Plan
Two levels of benefits are available with the DPPO plan: in-network and outof-network. You may see any dental provider for care, but you will pay less and get the highest level of benefits with in-network providers. You could pay more if you use an out-of-network provider.
*Out-of-Network Providers: Your benefits will be paid at the Maximum Allowable Charge (MAC) associated with the service received. If the provider billed higher than the MAC, then you are responsible for the difference.
**Out-of-Network Providers: Your benefits will be paid based on a 90th percentile of usual and customary allowance. If your dentist’s fee is lower than the scheduled fee, the plan will pay benefits based on the actual fee. If the fee is higher, the plan will pay benefits based only on the scheduled fee and you are responsible for the difference.
***The Rollover Benefit provision allows you and your dependents to save your dental benefit dollars for when you need them most. With this provision, Mutual of Omaha will “roll over” a percentage of the Policy Year Maximum for an insured person in a given Policy Year increasing the amount of the maximum for the insured person in the following Policy Year (subject to certain conditions).
VISION COVERAGE
Our vision plan offers quality care to help preserve your health and eyesight. Regular exams can detect certain medical issues such as diabetes and high cholesterol, in addition to vision and eye problems. You may seek care from any vision provider, but the plan will pay the highest level of benefits when you see a VSP network provider. Coverage is provided through Mutual of Omaha using the EyeMed Insight network.
LIFE AND AD&D INSURANCE
Life and Accidental Death and Dismemberment (AD&D) insurance through Mutual of Omaha are important to your financial security, especially if others depend on you for support or vice versa. With Life insurance, you or your beneficiary(ies) can use the coverage to pay off debts such as credit cards, loans, and bills. AD&D coverage provides specific benefits if an accident causes bodily harm or loss (e.g., the loss of a hand, foot, or eye). If death occurs from an accident, 100% of the AD&D benefit would be paid to you or your beneficiary(ies). Life and AD&D coverage amounts reduce by 65% at age 65, and 50% at age 70.
Basic Life and AD&D
Basic Life and AD&D insurance are provided at no cost to you. You are automatically covered at one times your annual salary up to a maximum $200,000 for each benefit.
Voluntary Life and AD&D
You may buy more Life and AD&D insurance for you and your eligible dependents. If you do not elect Voluntary Life and AD&D insurance when first eligible or if you want to increase your benefit amount at a later date, you may need to show proof of good health. If you are currently covered, you may increase by two increments with no Evidence of Insurability required. You must elect Voluntary Life and AD&D coverage for yourself before you may elect coverage for your spouse or children. If you leave the company, you may be able to take the insurance with you.
LIFE AND AD&D AVAILABLE COVERAGE
• Increments of $10,000 up to five times annual salary ($500,000 maximum)
Employee
Spouse
• Guaranteed Issue five times annual salary ($500,000 maximum) $150,000
• Increments of $5,000 up to 50% of employee amount up to $150,000
• Guaranteed Issue 100% of True Open Enrollment! A one-time open enrollment is available for a period of up to 90 days prior to the effective date of the policy. During this time, you may elect insurance for the first time or request increased insurance up to the Guaranteed Issue amount for you and your dependents (if applicable) without providing health information. Employee Benefit up to $30,000
• Increments of $1,000 up to $10,000 maximum
Child(ren)
• Guaranteed Issue: $10,000
Designating a Beneficiary
A beneficiary is the person or entity you elect to receive the death benefits of your Life and AD&D insurance policies. You can name more than one beneficiary, and you can change beneficiaries at any time. If you name more than one beneficiary, you must identify how much each beneficiary will receive (e.g., 50% or 25%).
DISABILITY INSURANCE
Disability insurance provides partial income protection if you are unable to work due to a covered accident or illness. We offer Voluntary Short Term Disability (VSTD) and Voluntary Long Term Disability (VLTD) insurance for you to purchase through Mutual of Omaha
Voluntary Short Term Disability
VSTD coverage pays a percentage of your weekly salary if you are temporarily disabled and unable to work due to an illness, pregnancy, or non-work-related injury. VSTD benefits are not payable if the disability is due to a job-related injury or illness. If a medical condition is job-related, it is considered workers’ compensation, not VSTD.
Rate per $10 of Benefit – $0.23
Calculate Voluntary STD:
• Weekly earnings x Benefit percentage .60 = Weekly benefit amount
• Weekly benefit amount x rate .023 = Estimated monthly deduction
*Benefits may not be paid for any condition treated within three months prior to your effective date until you have been covered under this plan for 12 months.
Voluntary Long Term Disability
VLTD insurance pays a percentage of your monthly salary for a covered disability or injury that prevents you from working for more than 90 days. Benefits begin at the end of an elimination period and continue while you are disabled — Required Beginning Date (RBD) to Social Security Normal Retirement Age (SSNRA).
Benefits Begin 91st day
You Receive
Maximum Benefit Period RBD to SSNRA
Pre-existing Condition Exclusion 12/12*
Rate per $100 of Benefit – $0.52
Calculate Voluntary LTD:
• Monthly earnings x Benefit percentage .60 = Covered monthly earnings
• Covered monthly earnings x rate .0052 = Estimated monthly deduction
*Benefits may not be paid for any condition treated within 12 months prior to your effective date until you have been covered under this plan for 12 months.
SUPPLEMENTAL INSURANCE
Accident Insurance
Accident insurance provides affordable protection against a sudden, unforeseen accident. The Accident plan helps offset the direct and indirect expenses resulting from an accident such as copayments, deductible, ambulance, physical therapy, and other costs not covered by traditional health plans. Some accidents covered under this plan include: dislocations, ruptured discs, eye injuries, lacerations, internal injuries, fractures, ambulance, accidental death and dismemberment, and hospital confinement. The chart shows some examples of the benefit amounts you could receive for covered services. Refer to the benefits summary for full details.
Voluntary Critical Illness
Voluntary Critical Illness Insurance from Mutual of Omaha helps cover some of the expenses associated with a serious illness. If you’re diagnosed with a specific critical illness while covered under Mutual of Omaha’s plan, you’ll receive a lump-sum benefit you can use however you need to.
The chart shows only a few of the covered services. For full details, refer to the benefit schedule.
CRITICAL ILLNESS INSURANCE
Some Benefit Amounts Available
Employee
Spouse
Increments of $5,000
$5,000 Minimum $100,000 Maximum
Increments of $1,000
$1,000 Minimum
50% of Employee’s benefit up to $50,000
Guaranteed Issue $10,000 Child
25% of Employee’s benefit up to $25,000* Condition
Carcinoma in situ; coronary artery disease 25% of benefit amount
6/12 Pre-existing Condition Exclusion1
*The amount of insurance for any dependent will be rounded to the next higher multiple of $1,000, if not already an even multiple of $1,000. NOTE: Child coverage begins at birth and terminates at age 26 unless the child is incapacitated.
1Benefits are not payable for any critical illness caused by, attributable to, or resulting from a pre-existing condition until 12 months after an insured person is continuously insured. A preexisting condition includes any critical illness for which an insured person received treatment in the six months prior to the date the person became insured. This limitation does not apply to newborn child(ren).
*Employee and Spouse premiums are calculated with the Employee’s age as of the effective date of the plan and will adjust once each year on the plan anniversary date that coincides with or follows the day an Employee reaches the starting age of the next age band. Child insurance is automatic. A separate premium is not required.
GLOSSARY OF TERMS
Beneficiary – Who will receive a benefit in the event of the insured’s death. A policy may have more than one beneficiary.
Coinsurance – Your share of the cost of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service, typically after you meet your deductible.
Copay – The fixed amount you pay for health care services received.
Deductible – The amount you owe for health care services before your health insurance begins to pay its portion. For example, if your deductible is $1,000, your plan does not pay anything until you meet your $1,000 deductible for covered health care services. The deductible may not apply to all services, including preventive care.
Employee Contribution – The amount you pay for your insurance coverage.
Employer Contribution – The amount Samson Controls contributes to the cost of your benefits.
Explanation of Benefits (EOB) – A statement sent by your insurance carrier that explains which procedures and services were provided, how much they cost, what portion of the claim was paid by the plan, what portion of the claim is your responsibility and information on how you can appeal the insurer’s decision. These statements are also posted on the carrier’s website for your review.
Flexible Spending Account (FSA) – An option that allows participants to set aside pretax dollars to pay for certain qualified expenses during a specific time period (usually a 12-month period).
Generic Drugs – Drugs approved by the U.S. Food and Drug Administration (FDA) to be chemically identical to corresponding brand name versions. The color or flavor of a generic medicine may be different, but the active ingredient is the same. Generic
Health Savings Account (HSA) – A personal savings account that allows you to pay for qualified medical expenses with pretax dollars.
High Deductible Health Plan (HDHP) – A medical plan with a higher deductible in exchange for a lower monthly premium. You must meet the annual deductible before any benefits are paid by the plan.
In-Network – Doctors, hospitals, and other providers that contract with your insurance company to provide health care services at discounted rates.
Out-of-Network – Doctors, hospitals, and other providers that are not contracted with your insurance company. If you choose an out-of-network provider, you may be responsible for costs over the amount allowed by your insurance carrier.
Out-of-Pocket Maximum – Also known as an out-of-pocket limit. The most you pay during a policy period (usually a 12-month period) before your health insurance or plan begins to pay 100% of the allowed amount. The limit does not include your premium, charges beyond the Reasonable & Customary (R&C) or health care your plan does not cover. Check with your health insurance carrier to confirm what payments apply to the out-of-pocket maximum.
Over-the-Counter (OTC) Medications –Medications typically made available without a prescription.
Prescription Medications – Medications prescribed by a doctor. Cost of these medications is determined by their assigned tier.
Preventive Care – The care you receive to prevent illness or disease. It also includes counseling to prevent health problems.
Reasonable and Customary Allowance –(R&C) – Also known as an eligible expense or the Usual and Customary (U&C). The amount your insurance company will pay for a medical service in a geographic region based on what providers in the area usually charge for the same or similar medical service.
SSNRA – Social Security Normal Retirement Age.
LEGAL AND ID THEFT PROTECTION
If you need guidance and assistance with legal consultation, family matters, or small claims court assistance, work with local plan attorneys through LegalShield. Protect your identity with IDShield
Legal Protection
Put a law firm in the palm of your hand with LegalShield. Benefits include:
z Family matters (e.g., adoption, elder care, juvenile court, prenuptial agreements)
z Financial (e.g., affidavits, consumer protection, tax audit and collection service, bankruptcy)
z Home (e.g., boundary or title disputes, deeds, foreclosure, mortgages)
z Estate planning (e.g., probate, trusts, wills and codicils, living wills)
z Auto (e.g., driver’s license restoration, moving traffic violations, motor vehicle property damage)
z General (e.g., 24/7 emergency access, document review, demand letters and phone calls on your behalf, consultations)
Identity Theft Protection
Millions of people have their identity stolen each year. IDShield provides identity theft protection and identity restoration services for you, your spouse, and up to 10 dependents. Benefits include:
z Monitored information (e.g., email, phone, account numbers, names)
z Privacy and security monitoring (e.g., internet and dark web, social media)
z Comprehensive source monitoring (e.g., global black market, online chat rooms, social feeds)
z Unlimited consultation (e.g., child identity theft, credit reports, data breaches)
z Complete identity restoration ($1 million protection policy, unlimited service guarantee)
z General (e.g., 24/7 emergency access, alerts, access to licensed private investigators)
z Financial account monitoring and a $1 million identity fraud protection plan for unauthorized electronic fund transfers and identity theft related expenses
EMPLOYEE ASSISTANCE PROGRAM
As Mutual of Omaha plan members, you and your family have access to free, confidential resources to help handle life’s challenges through the Employee Assistance Program (EAP). The EAP can help you cope with a variety of personal or work-related issues.
Counseling Services – Get in-person or virtual counseling for personal or work issues. Meet with a licensed EAP professional in person, by text, or by live chat, video or phone sessions. Three counseling sessions per year are included.
Legal, Financial, and Identity Theft Services – Receive up to 60 minutes of free consultation concerning legal issues, financial wellness and planning, and identity theft resources.
Work-Life Web Services – Access webinars, live talks, and articles on issues that are important to you, such as elder care, parenting, and more.
Contact Mutual of Omaha for support at any hour of the day or night: Visit www.mutualofomaha.com/eap
Call 800-316-2796
TTY 711
Worldwide Travel Assistance
AXA Assistance USA provides travel assistance for you and your dependents if you are traveling on any single trip more than 100 miles from home. Contact a representative to get pre-trip planning; translation, interpreter, or legal services; lost baggage assistance; emergency funds; document replacement; medical emergency help; and more. Services are available for business and personal travel.
For inquiries within the U.S.: 800-856-9947 Outside
EMPLOYEE CONTRIBUTIONS
Your Semimonthly Rates
This is not an enrollment form. Enroll through BenefitsinHand.
LEGAL 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:
October 1, 2025 Samson Controls Inc. 4111 Cedar Blvd Baytown, TX 77523 281-383-3677
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 Samson Controls Inc. 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. Samson Controls Inc. has determined that the prescription drug coverage offered by the Samson Controls Inc. 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.
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 Samson Controls Inc. 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 Samson Controls Inc. 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 281-3833677.
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 800-7721213. TTY users should call 800-325-0778
LEGAL NOTICES
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).
October 1, 2025
Samson Controls Inc. 4111 Cedar Blvd Baytown, TX 77523
281-383-3677
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 Samson Controls Inc., hereinafter referred to as the plan sponsor.
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.
Samson Controls Inc. 4111 Cedar Blvd Baytown, TX 77523
281-383-3677
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/healthinsurance-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 Samson Controls Inc. group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the Samson Controls Inc. 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.
Plan Contact Information
Samson Controls Inc. 4111 Cedar Blvd Baytown, TX 77523 281-383-3677
LEGAL NOTICES
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. Outof-network 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 innetwork 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:
• Emergency services – If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s innetwork cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
• 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-ofnetwork. 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, outof-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 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 employment-based 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 employment-based coverage. Also, this employer contribution -as well as your employee contribution to employment-based 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.
LEGAL NOTICES
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 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-medicaid-chip/ for more details.
How Can I Get More Information?
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: Samson Controls, Inc.
5. Employer Address: 4111 Cedar Blvd., Baytown, TX 77523
4. Employer Identification Number (EIN): 76-0368258
6. Employer Phone Number: (281) 383-3677
7. City: Baytown 8. State: TX 9. ZIP Code: 77523
10. Who can we contact at this job?: Julie Villarreal
11. Phone Number (if different from above):
12. E-Mail Address: Julie.villarreal@samsongroup. com
You are not eligible for health insurance coverage through this employer. You and your family may be able to obtain health coverage through the Marketplace, with a new kind of tax credit that lowers your monthly premiums and with assistance for out-of-pocket costs.
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 the Samson Controls, Inc. employee benefits program. It does not include all plan rules, details, limitations, and exclusions. The terms of your benefits 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. Samson Controls, Inc. reserves the right to change or discontinue its employee benefits program at anytime.