2026-2027 MB2 Dental Solutions Benefits Book

Important Contacts

Travel Assistance Mutual of Omaha/ AXA Assistance USA 800-856-9947 www.mutualofomaha.com Identity Theft Support Mutual of Omaha/ AXA Assistance USA 800-856-9947 www.mutualofomaha.com Will Preparation Mutual of Omaha/Epoq

www.willprepservices.com (use code MUTUALWILLS to register)

Employee Response Center

Employee benefits can be complicated, but we can help! Employee Response Center representatives can assist you with the following:

z Benefits information

z Claims and billing questions

z Eligibility issues

Call or text 844-745-MB2D (6223) to speak with a 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. Bilingual representatives are available. You can also email questions or requests to mb2dental@eb.higginbotham.net.

Need Enrollment Help?

MB2 Dental offers one-on-one enrollment support by phone. Scan the QR code to schedule.

What’s Inside

We are pleased to offer a full benefits package to you and your eligible dependents. Read this guide to know what benefits are available to you.

Availability of Summary Health Information

Our benefits program offers one or more medical plan options. To help you make an informed choice, review each plan’s Summary of Benefits and Coverage, available from Human Resources.

Eligibility

Who is Eligible for Benefits

Who is Eligible

When to Enroll

When Coverage Starts

ƒ A regular, full-time employee working an average of 30 hours or more per week

ƒ Within the first 30 days of employment

ƒ A regular, full-time employee working an average of 30 hours or more per week

ƒ During OE or for a QLE

ƒ First of the month after completing 60 days of full-time employment ƒ OE: Start of the plan year ƒ QLE: On the date of the event

Qualifying Life Events

OE: Open Enrollment

QLE: Qualifying Life Event

ƒ Your legal spouse

ƒ Children under age 26 regardless of student, dependency, or marital status

ƒ Children age 26 or older 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

ƒ During OE or for a QLE

ƒ When covering dependents, you must enroll for and be on the same plans

Ask Human Resources

You may only enroll for or make changes to coverage during the plan year if you are a new hire or if you have a QLE, such as:

You have 30 days from the event date to notify Human Resources and complete your changes. You may need to provide documents to verify the

How to Enroll Online

Enrolling in benefits is simple through Paycom.

To begin the enrollment process, go to the www.paycom.com Notifications Center.

1. Go to Benefits Enrollment for the current plan year and click on Start Enrollment

2. Review your information. Click Edit to make changes and/or Next to continue.

3. Complete the pre-enrollment questions and click Save and Next. You can also edit dependent and beneficiary information on this screen.

4. Choose to enroll or decline by clicking the appropriate option, and add dependents as needed. When finished, click Enroll and continue this for each plan.

5. When you are finished, review your enrollment and click Finalize. Then, tap Sign and Submit in the pop-up window.

Need Enrollment Help?

MB2 Dental offers one-on-one enrollment support by phone. Scan the QR code to schedule.

Medical Coverage

As with our past medical plans, we continue to offer coverage through Blue Cross Blue Shield of Texas (BCBSTX).

The plans are designed to give you access to highquality, board-certified providers while helping you manage your time and out-of-pocket costs.

High Deductible Health Plan

A High Deductible Health Plan (HDHP) allows you to see any provider when you need care, and you will pay less 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).

Preferred Provider Organization

A Preferred Provider Organization (PPO) plan allows you to see any provider when you need care. When you see in-network providers, 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 innetwork providers, your office visits, urgent care visits, and prescription drugs are covered with a copay, and most other services are covered at the deductible and coinsurance level.

Administrator:

Network: Blue Choice

Medical Plan Options

You have a choice of three plans:

z Standard Plan – This plan is an HDHP.

z Mid Plan – This plan is a PPO.

z Buy-up Plan – This plan is a PPO.

Visit www.myblueelementtx.com. Call 855-496-7575. Download the Blue Element TX app

z Benefits and claims support

z Find a doctor or hospital

z Health care advocacy – advocates will help you find and schedule the best care at little to no cost.

Medical Benefits Summary

1

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Prescription Drugs

Your medical coverage includes prescription benefits for retail, mail order (home delivery), and specialty drugs.

Prescription Drug List

Your medical carrier controls prescription drug costs by negotiating discounts on medications. Covered drugs are listed in the Prescription Drug List. If you take maintenance medications, review the list with your doctor to see which ones are covered and available. If your medication is not listed, call the phone number on your member ID card.

RETAIL

Use any participating retail pharmacy to fill short-term, non-specialty medications. Retail pharmacies often fill or refill 30- to 90-day supplies.

HOME DELIVERY

If you take medication on a daily basis, consider using home delivery. It is a convenient, low-cost option that delivers up to a 90-day supply right to your home. You will need to set up an online pharmacy account and/or download the app to easily manage your prescriptions.

SPECIALTY

If you need a specialty drug to treat a complex or chronic condition, you will be asked to enroll in a specialty drug program. It offers support to ensure the medication works well for you and costs as little as possible. If you do not enroll in the program, the specialty drug may not be covered. Certain exclusions and limitations apply. Visit www.vytlonespecialty.com. Call 866-629-6779.

Up for Home Delivery Visit https://members.vytlone.com. Call 800-687-0707

Generic drugs are a safe and effective option to brand-name drugs – and they cost much less! They have the same active ingredients, strength, and dosage as brand-name drugs, and they also meet the same rigorous quality and safety standards set by the Food and Drug Administration.

$0 International Prescription Programs

We provide affordable options for certain brand name and specialty prescriptions.

International prescription programs provide $0 cost, free shipping, and a steady supply for eligible medications. To be eligible, you must already be taking the drug for at least 30 days without complications.

CANARX – Brand-Name Maintenance Drugs

If you take a common brand-name medication on a long-term basis, CANARX may be the right choice. The program focuses on maintenance drugs used to manage ongoing health conditions and offers a reliable, cost-free alternative to your regular pharmacy.

Visit www.canarx.com

Call 866-893-6337. Physicians can fax 866-715-6337

How to Order

Carriers: CANARX and ElectRx

ElectRx – Specialty and Diabetic Medications

If you have a complex condition that requires specialty or diabetic drugs, ElectRx provides a streamlined, $0-cost way to access these high-cost medications. The program ensures continuity of care while eliminating copays and out-of-pocket costs.

Email info@electrx.com. Call 855-353-2879

Mail to A&M Pharmacy – NCPDP: 2338514 at 8282 Woodward Ave., Detroit, MI 48202

z Have your doctor fax the prescription (with three refills).

z For CANARX, visit the website and enroll your prescription online, or download and mail in the form.

z For ElectRx, email the prescription.

z Call Customer Service to order for you.

The typical supply is for three months. The first order may take up to four weeks; refills ship in five to 15 business days. You will receive a call before each refill, including reminders.

Preventive Care

Your

medical plans offer $0 preventive care for everyone.

Preventive care is the care you receive to help prevent chronic illness or disease. It includes exams, lab work, screenings, immunizations, and counseling to prevent health problems, such as diabetes or heart disease.

Preventive Care Coverage Includes

Adults

Cholesterol screening

Blood pressure screening

Colorectal cancer screening

Lung cancer screening

Hepatitis B screening

Well visits

Bone density screening

Obesity screening

Diabetes type 2 screening

Depression screening

Mammograms

Cervical cancer screening

Immunizations

Teens

Physical exam

Blood tests for iron and cholesterol

Anxiety screening

Growth screening

Hearing screening

Hepatitis B screening

Depression screening

Alcohol, tobacco, and drug use assessments

Tuberculosis screening Immunizations

Children

Autism screening

Blood screening

Depression screening

Developmental screening

Hearing screening

Obesity screening and counseling

Hypothyroidism screening

Behavioral assessments

Well visits

Immunizations

Frequently Asked Questions

Why should I get preventive care?

Preventive care is the fastest and best way to uncover potential risks and avoid chronic health conditions.

Are all screenings, tests, and procedures covered under preventive care?

No. Your doctor will be able to advise you as to the preventive care you need or should obtain, based on your medical and family history.

Why did I get a bill for preventive care?

Diagnosis codes on the doctor’s bill must meet certain insurance company conditions for them to be processed as preventive and covered at 100%. If you have a medical concern, or your doctor finds a specific medical issue during your preventive care doctor’s visit, a diagnosis code for that issue or concern will be on your bill. As a result, the insurance company may process the bill for a specific medical condition, not preventive care. In this case, you must pay the copay or portion of your deductible.

Radish Health

Radish

Health offers an integrated virtual primary, urgent, and mental health care service with 24/7 access to physicians via app messaging and video visits.

Radish: More Than Telemedicine

Radish gives you convenient access to care while also helping you navigate the health care system with confidence.

With Radish, you can:

z Connect with primary care physicians

z Get help managing chronic conditions and preventive care

z Receive guidance on diagnoses, treatment options, and next steps

z Find and coordinate care with in-network specialists

z Access care navigation support to avoid unnecessary costs

Radish is designed to simplify your health care experience while providing trusted clinical care, navigation assistance, and ongoing support all in one place.

Get More Information or Register

Skip the trip to your doctor! Register for an account so you can get on-demand medical care.

Visit https://patient.radish.health/login. Call 833-4-RADISH (472-3474). Download the Radish Health app

You pay $0 per consult if you are enrolled in any of our medical plans.

When to Use Telemedicine

While telemedicine does not replace your primary care physician, it is a convenient and cost-effective option when you need care and:

z Have a non-emergency issue and are considering an after-hours health care clinic, urgent care clinic, or emergency room for treatment

z Are on a business trip, vacation, or away from home

z Are unable to see your primary care physician

Use telemedicine for minor conditions such as:

z Sore throat

z Headache

z Stomachache

z Cold/flu

z Allergies

z Dermatology

z Primary care

z Fever

z Urinary tract infections

Do not use Radish Health for serious or life-threatening emergencies.

Advanced Lab Tests and Health Screenings

New! Voluntary Function Membership

Get a deeper understanding of your body and spot potential issues early.

Your benefits plan includes the opportunity for you and your family to enroll in a Function membership. Function empowers you to own your health through affordable access to advanced lab testing. A Function membership evaluates five times more biomarkers than the average physical, helping you gain a deeper understanding of what’s going on in your body, monitor for early indicators of disease, and track your health as it evolves.

The membership includes:

z Access to 100+ lab tests at the start of your membership

z Access to an additional 60+ midyear follow-up tests to track your progress

z Detailed clinician notes highlighting areas of focus

z A targeted action plan to help improve your health

z Results stored on one secure platform for easy access anytime

HOW THE PROCESS WORKS

After signing up for Function, you will get an email and text message to schedule a convenient time and location for your lab visit. Tests take less than 30 minutes and are done at one of more than 2,000 partner lab locations nationwide. You will then get a detailed summary of your results and a targeted action plan to help you reach your health goals. All results are stored in one secure location for you to access anytime. You can retest in six months to see how you are progressing. Nonroutine tests (e.g., advanced MRI, early detection of multiple cancers, allergies, heavy metals, and more) may be added for an additional cost.

The cost for an individual annual membership* is $335!

HOW TO ENROLL

Enroll anytime during the year by accessing www.functionhealth.com/aep/higginbotham. You will pay the membership fee(s) directly to Function.

HSA ELIGIBLE

Funds from your Health Savings Account (HSA) may be used to pay for your membership. Reimbursement is not guaranteed, so please contact your HSA provider in advance to confirm the terms of reimbursement. If you do not have an HSA, use a personal credit card.

*Function membership includes prepaid access to 160+ lab tests each year at a Quest Diagnostics site. Due to state regulations, members testing in New York and New Jersey will be charged an additional fee directly by Quest for each lab visit. We cannot accommodate lab testing in Hawaii or Rhode Island at this time. You can schedule lab testing in a neighboring state.

Health Care Options

Becoming familiar with your options for medical care can save you time and money.

TELEMEDICINE

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 Infections Sore and strep throat

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

infections

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

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

24 hours a day, 7 days a week Most

BCBSTX Resources

Member Portal and App

Blue Element is the secure BCBSTX member website where you can:

z Check claim status or history

z Confirm dependent eligibility

z Sign up for electronic Explanation of Benefits statements

z Locate in-network providers

z Print or request an ID card

z Review your benefits

z Get tips to live and eat healthier

Get the Blue Element TX app for easy access to your information. Log in from your mobile device to access your Blue Element account.

BlueCare Dental Connection

ID Cards

You will have one card for your medical and prescription benefits, and a separate card for dental.

BlueCare Dental Connection provides free educational information and other resources to help you make decisions about your dental care. Access the online Dental Wellness Center 24/7 to ask dental questions, find in-network dentists, get local dental costs, view videos, and more. Log in to www.myblueelementtx.com and search for Dental Wellness Center.

Dental Coverage

Our dental plan helps you maintain good oral health through affordable options for preventive care, including regular checkups and other dental work.

DPPO Plan

Two levels of benefits are available with the DPPO plan: in-network and out-of-network. You may see any dental provider for care, but you will pay less and get the highest level of benefits with innetwork providers. You could pay more if you use an out-of-network provider.

Vision Coverage

Health Savings Account

Offset your HDHP health care costs, reduce your taxes, and get a long-term tax-advantaged savings account.

An HSA is like a personal savings account that allows you to pay for current or future health care expenses with pretax dollars or save the funds for retirement. The funds can also be used for your dependents, even if they are not covered by the HDHP. An HSA is always yours to keep, even if you change health plans or jobs.

Triple Tax Benefits

How to Pay or Get Reimbursed

z Use your HSA debit card to pay for qualified expenses.

z Pay out-of-pocket and submit your receipts for reimbursement online or through the app.

Health Savings Account

HSA Eligibility

You are eligible to open and contribute to an HSA if you are:

z Enrolled in an HSA-eligible HDHP

z Not covered by another plan that is not a qualified HDHP (e.g., 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

Note: You may have an HSA at the financial institution of your choice, but only accounts opened through WEX are eligible for automatic payroll deductions and company contributions.

Two Ways to Use Your HSA

USE THE MONEY NOW

Pay for qualified out-of-pocket medical, dental, and vision expenses as they are incurred.

INVEST OVER TIME

Invest and grow your HSA dollars tax-free. You can use the funds to pay for qualified expenses later.

Contributions

You may contribute up to the IRS annual maximum. Your employer also makes a contribution to your HSA that totals the following annual amount:

If you are age 55 or older, you can contribute an extra $1,000.

Qualified HSA Expenses

Typical expenses eligible for payment under your HSA are listed below.

z Abdominal supports

z Acupuncture

z Air conditioner (when necessary for relief from difficulty in breathing)

z Alcoholism treatment

z Ambulance

z Anesthetist

z Arch supports

z Artificial limbs

z Autoette (when used for relief of sickness/ disability)

z Blood tests

z Blood transfusions

z Braces

z Cardiographs

z Chiropractor

z Contact lenses

z Convalescent home (for medical treatment only)

z Crutches

z Dental treatment

z Dental X-rays

z Dentures

z Dermatologist

z Diagnostic fees

z Diathermy

z Drug addiction therapy

z Drugs (prescription)

z Elastic hosiery (prescription)

z Eyeglasses

z Fees paid to health institute prescribed by a doctor

z FICA and FUTA tax paid for medical care service

z Fluoridation unit

z Guide dog

z Gum treatment

z Gynecologist

z Healing services

z Hearing aids and batteries

z Hospital bills

z Hydrotherapy

z Insulin treatment

z Lab tests

z Lead paint removal

z Legal fees

z Lodging (away from home for outpatient care)

This list is not all-inclusive; additional expenses may qualify and the items listed may change in accordance with IRS regulations. Refer to IRS Publication 502 Medical and Dental Expenses at www.irs.gov for complete details.

z Metabolism tests

z Neurologist

z Nursing (including board and meals)

z Obstetrician

z Operating room costs

z Ophthalmologist

z Optician

z Optometrist

z Oral surgery

z Organ transplant (including donor’s expenses)

z Orthopedic shoes

z Orthopedist

z Osteopath

z Oxygen and oxygen equipment

z Pediatrician

z Physician

z Physiotherapist

z Podiatrist

z Postnatal treatments

z Practical nurse for medical services

z Prenatal care

z Prescription medicines

z Psychiatrist

z Psychoanalyst

z Psychologist

z Psychotherapy

z Radium therapy

z Registered nurse

z Special school costs for the handicapped

z Spinal fluid test

z Splints

z Surgeon

z Telephone or TV equipment to assist the hard-of-hearing

z Therapy equipment

z Transportation expenses (relative to health care)

z Ultraviolet ray treatment

z Vaccines

z Vitamins (if prescribed)

z Wheelchair

z X-rays

Life and AD&D Insurance

Life and Accidental Death and Dismemberment (AD&D) insurance

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 to 67% at age 65.

Basic Life and AD&D

Basic Life and AD&D insurance are provided at no cost to you. You are automatically covered at $15,000 for each benefit.

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 anytime. If you name more than one beneficiary, you must identify how much each beneficiary will receive (e.g., 50% or 25%).

Voluntary Life and AD&D

If you need more coverage than Basic Life and AD&D, you may buy Voluntary Life and AD&D for yourself and your dependent(s). 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 Evidence of Insurability (EOI). You must elect Voluntary Life and AD&D coverage for yourself before covering your spouse and/or child(ren).

ONLY FOR 2026! TRUE OPEN ENROLLMENT

Since we are moving to Mutual of Omaha, you have an opportunity to enroll for or increase your Voluntary Life and AD&D coverage up to the Guaranteed Issue amount without EOI (i.e., proof of good health). This opportunity is only available at Open Enrollment. If your existing coverage exceeds the Guaranteed Issue amount, it will be grandfathered. If you decline this opportunity and enroll for or increase your coverage at a later date, EOI may be required.

Spouse

Child(ren)

ƒ Increments of $10,000 up to $500,000

ƒ New hire Guaranteed Issue $250,000

ƒ Increments of $5,000 up to $250,000 not to exceed 100% of employee amount

ƒ New hire Guaranteed Issue $50,000

ƒ $10,000

ƒ New hire Guaranteed Issue $10,000

ƒ Birth to 14 days – $0 Carrier: Mutual of

FOR RATES

Please see Paycom for Voluntary Life and AD&D rates.

Disability Insurance

Disability insurance provides partial income protection if you are unable to work due to a covered accident or illness. We offer Short Term Disability (STD) and Long Term Disability (LTD) for you to purchase.

Voluntary Short Term Disability

STD coverage pays a percentage of your weekly salary if you are temporarily disabled and unable to work due to an illness, pregnancy, or non-workrelated injury. STD 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 STD.

Note: Voluntary STD 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 six months.

Voluntary Long Term Disability

LTD insurance pays a percentage of your monthly salary for a covered disability or injury that prevents you from working for a specific period of time. Benefits begin at the end of an elimination period and continue while you are disabled up to the maximum benefit period.

Note: Voluntary LTD 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.

Additional Benefits

Mutual of Omaha provides the following programs and services at no cost to you.

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 trip planning assistance; 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.

z For inquiries within the USA, call 800-856-9947.

z From outside the USA, call 312-935-3658

Identity Theft Services

The Identity Theft Assistance program, provided by AXA Assistance USA, helps you understand the risks of identity theft and how to prevent it. If your information is compromised, a representative will connect you with the needed resources.

z Call 800-856-9947 to learn more.

Will Preparation

Creating a will is an important investment in your future. In just minutes, you can create a personalized will that keeps your information safe and secure. The services provided by Epoq offer a secure account space to prepare wills and other legal documents.

z Log in at www.willprepservices.com and use the code MUTUALWILLS to register.

Supplemental Coverage

Accident Insurance

Accident insurance provides affordable protection against a sudden, unforeseen accident.

Accident insurance helps offset the direct and indirect expenses such as copayments, deductibles, ambulance, physical therapy, childcare, rent, and other costs not covered by traditional health plans. You will be paid a specific sum of money directly based on the care and services provided for your covered accident. Use the money any way you see fit. See the plan document for full details.

Indemnity Insurance

Hospital Indemnity insurance helps you with the high cost of medical care by paying you a cash benefit when you have an inpatient hospital stay or are admitted to an intensive care unit. You decide how to use the funds, whether it’s to pay for bills, gas, childcare or eldercare, medication, or other out-of-pocket expenses. See the plan document for full details.

ƒ

Supplemental Coverage

Critical Illness Insurance

Critical Illness insurance helps pay the cost of non-medical expenses related to a covered critical illness or cancer.

The plan provides a lump sum benefit payment to you upon first and second diagnosis of any covered critical illness or cancer. The benefit can help cover expenses such as lost income, out-of-town treatments, special diets, daily living, and household upkeep costs. See the plan document for full details.

or

or $30,000 Spouse – Up to 50% of employee amount Child – Up to 50% of employee amount

For conditions such as coma; heart attack; heart, kidney, or organ failure; invasive cancer; paralysis; stroke; and more

For conditions such as non-invasive cancer and more

Skin Cancer

Lifetime benefit for initial skin cancer diagnosis

Childhood Conditions

For childhood conditions such as cleft lip or palate; cystic fibrosis; Down syndrome; spina bifida; and more

FOR RATES

Please see Paycom for Critical Illness Insurance age-based rates. Benefits for employees located in the state of New York may differ. Refer to your employee benefits book for details.

Employee Assistance Program

The Employee Assistance 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:

z Relationships

z Work-life balance

z Stress and anxiety

z Will preparation and estate resolution

z Grief and loss

z Childcare and eldercare issues

z Substance abuse

z Financial and legal matters

z And more

.

Support at any hour of the day or night!

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:

MB2 Dental, PLLC

Human Resources 2403 Lacy Lane Carrollton, TX 75006 972-869-3789 ext. 194

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 MB2 Dental, PLLC 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. MB2 Dental, PLLC has determined that the prescription drug coverage offered by the MB2 Dental, PLLC 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.

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 MB2 Dental, PLLC 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 MB2 Dental, PLLC 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 972-869-3789 ext. 194.

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 (1-800-6334227). TTY users should call 877-4862048

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 800-772-1213. 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).

April 1, 2026

MB2 Dental, PLLC Human Resources

2403 Lacy Lane Carrollton, TX 75006 972-869-3789 ext. 194

Notice of HIPAA Privacy Practices

THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices (the “Notice”) describes the legal obligations of MB2 Dental, PLLC’s Group Health Plan (the “Plan”) and your legal rights regarding your protected health information held by the Plan under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act). Among other things, this Notice describes how your protected health information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law.

We are required to provide this Notice of Privacy Practices to you pursuant to HIPAA.

The HIPAA Privacy Rule protects only certain medical information known as “protected health information.” Generally, protected health information (PHI) is health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan, from which it is possible to individually identify you and that relates to:

1. Your past, present, or future physical or mental health or condition;

2. The provision of health care to you; or 3. The past, present, or future payment for the provision of health care to you.

I. Contact Information

If you have any questions about this Notice or about our privacy practices, and for any correspondence or requests related to the contents of this Notice, please contact:

MB2 Dental, PLLC Human Resources 2403 Lacy Lane Carrollton, TX 75006 972-869-3789 ext. 194

II. Effective Date

This Notice is effective February 15, 2026.

III. Our Responsibilities

We are required by law to:

1. maintain the privacy of your PHI;

2. provide you with certain rights with respect to your PHI;

3. provide you with a copy of this Notice of our legal duties and privacy practices with respect to your PHI; and 4. follow the terms of the Notice that is currently in effect.

We reserve the right to change the terms of this Notice and to make new provisions regarding your PHI that we maintain, as allowed or required by law. If we make any material change to this Notice, we will provide you with a copy of our revised Notice of Privacy Practices.

IV. How We May Use and Disclose Your PHI

Under the law, we may use or disclose your PHI under certain circumstances without your permission. The following categories describe the different ways that we may use and disclose your PHI. For each category of uses or disclosures we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. Note that we will use and disclose PHI as described below unless otherwise prohibited or restricted by applicable state or other law, and that information can lose its protected status as PHI once re-disclosed by a recipient.

For Treatment. When and as appropriate, we may use or disclose medical information about you to facilitate medical treatment or services by health care providers. We may disclose medical information about you to providers, including doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you. For example, we might disclose information about you with physicians who are treating you.

For Payment. We may use or disclose your protected health information to determine your eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, we may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational, or medically necessary, or to determine whether the Plan will cover the treatment. We may also share your protected health information with a utilization review or pre-certification service provider. Likewise, we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments.

For Health Care Operations. We may use and disclose your protected health information for other Plan operations. These uses and disclosures are necessary to run the Plan. For example, we may use medical information in connection with conducting quality assessment and improvement activities; underwriting, premium rating, and other activities relating to Plan coverage; submitting claims for stop-loss (or excess-loss) coverage; conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs; business planning and development such as cost management; and business management and general Plan administrative activities. However, we will not use your genetic information for underwriting purposes.

Substance Use Disorder (SUD) Treatment

Information. Some of your health information may be part of a SUD patient record and subject to additional protections under federal law (42 CFR Part 2) governing confidentiality of SUD patient records. If we receive or maintain any information about you from a SUD treatment program that is covered by 42 CFR Part 2 (a “Part 2 Program”) through a general consent you provide to the Part 2 Program to use and disclose the SUD patient record for purposes of treatment, payment or health care operations, we may use and disclose your SUD patient record for treatment, payment and health care operations purposes as described in this Notice. If we receive or maintain your SUD patient record through specific consent you provide to us or another third party, we will use and disclose your SUD patient record only as expressly permitted by you in your consent as provided to us. In no event will we use or disclose your SUD patient record, or testimony that describes the information contained in your SUD patient record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order. To Business Associates. We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services. In order to perform these functions or to provide these services, Business Associates will receive, create, maintain, transmit, use, and/or disclose your PHI, but only after they agree in writing with us to implement appropriate safeguards regarding your PHI. For example, we may disclose your PHI to a Business Associate to process your claims for Plan benefits or to provide support services, such as utilization management, pharmacy benefit management, or subrogation, but only after the Business Associate enters into a Business Associate contract with us.

Treatment Alternatives or Health-Related Benefits and Services. We may use and disclose your protected health information to send you information about treatment alternatives or other health-related benefits and services that might be of interest to you.

As Required by Law. We will disclose your PHI when required to do so by federal, state, or local law. For example, we may disclose your PHI when required by national security laws or public health disclosure laws.

To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, we may disclose your PHI in a proceeding regarding the licensure of a physician.

To Plan Sponsors. For the purpose of administering the plan, we may disclose PHI to certain employees of the Employer. However, those employees will only use or disclose that information as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized further disclosures. Your PHI cannot be used for employment purposes without your specific authorization.

V. Special Situations

In addition to the above, the following categories describe other possible ways that we may use and disclose your PHI without your specific authorization. For each category of uses or disclosures, we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Organ and Tissue Donation. If you are an organ donor, we may release your PHI after your death to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation.

Military. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.

Workers’ Compensation. We may release your PHI for workers’ compensation or similar programs, but only as authorized by, and to the extent necessary to comply with, laws relating to workers’ compensation and similar programs that provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose your PHI for public health activities. These activities generally include the following:

1. to prevent or control disease, injury, or disability;

2. to report births and deaths;

3. to report child abuse or neglect;

4. to report reactions to medications or problems with products;

5. to notify people of recalls of products they may be using;

6. to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

7. to notify the appropriate government authority if we believe that a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree, or when required or authorized by law.

Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone involved in a legal dispute, but only if efforts have been made to tell you about the request or to obtain a court or administrative order protecting the information requested.

Law Enforcement. We may disclose your PHI if asked to do so by a law-enforcement official.

1. in response to a court order, subpoena, warrant, summons, or similar process;

2. to identify or locate a suspect, fugitive, material witness, or missing person;

3. about the victim of a crime if, under certain limited circumstances, we are unable to obtain the victim’s agreement;

4. about a death that we believe may be the result of criminal conduct; and

5. about criminal conduct.

Coroners, Medical Examiners, and Funeral Directors. We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors, as necessary to carry out their duties.

National Security and Intelligence Activities. We may release your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Inmates. If you are an inmate of a correctional institution or are in the custody of a law-enforcement official, we may disclose your PHI to the correctional institution or law-enforcement official if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

Research. We may disclose your PHI to researchers when:

6. The individual identifiers have been removed; or

7. When an institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of the requested information and approves the research.

VI. Required Disclosures

The following is a description of disclosures of your PHI we are required to make.

Government Audits. We are required to disclose your PHI to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA privacy rule.

Disclosures to You. When you request, we are required to disclose to you the portion of your PHI that contains medical records, billing records, and any other records used to make decisions regarding your health care benefits. We are also required, when requested, to provide you with an accounting of most disclosures of your PHI if the disclosure was for reasons other than for payment, treatment, or health care operations, and if the PHI was not disclosed pursuant to your individual authorization.

VII. Other Disclosures

Personal Representatives. We will disclose your PHI to individuals authorized by you, or to an individual designated as your personal representative, attorneyin-fact, etc., so long as you provide us with a written notice/authorization and any supporting documents (i.e., power of attorney). Note: Under the HIPAA privacy rule, we do not have to disclose information to a personal representative if we have a reasonable belief that:

1. You have been, or may be, subject to domestic violence, abuse, or neglect by such person; or

2. Treating such person as your personal representative could endanger you; and

3. In the exercise of professional judgment, it is not in your best interest to treat the person as your personal representative.

Spouses and Other Family Members. With only limited exceptions, we will send all mail to the employee. This includes mail relating to the employee’s spouse and other family members who are covered under the Plan and includes mail with information on the use of Plan benefits by the employee’s spouse and other family members and information on the denial of any Plan benefits to the employee’s spouse and other family members. If a person covered under the Plan has requested Restrictions or Confidential Communications (see below under “Your Rights”), and if we have agreed to the request, we will send mail as provided by the request for Restrictions or Confidential Communications.

Authorizations. Other uses or disclosures of your PHI not described above will only be made with your written authorization. For example, in general and subject to specific conditions, we will not use or disclose your psychiatric notes; we will not use or disclose your PHI for marketing; and we will not sell your PHI, unless you give us a written authorization. You may revoke written authorizations at any time, so long as the revocation is in writing. Once we receive your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.

VIII. Your Rights

You have the following rights with respect to your PHI:

Right to Inspect and Copy. You have the right to inspect and copy certain PHI that may be used to make decisions about your Plan benefits. If the information you request is maintained electronically, and you request an electronic copy, we will provide a copy in the electronic form and format you request, if the information can be readily produced in that form and format; if the information cannot be readily produced in that form and format, we will work with you to come to an agreement on form and format. If we cannot agree on an electronic form and format, we will provide you with a paper copy.

To inspect and copy your PHI, you must submit your request in writing. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed by submitting a written request.

Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan.

To request an amendment, your request must be made in writing. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

1. is not part of the medical information kept by or for the Plan;

2. was not created by us, unless the person or entity that created the information is no longer available to make the amendment;

3. is not part of the information that you would be permitted to inspect and copy; or

4. is already accurate and complete.

If we deny your request, you have the right to file a statement of disagreement with us and any future disclosures of the disputed information will include your statement.

Right to an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your PHI. The accounting will not include (1) disclosures for purposes of treatment, payment, or health care operations; (2) disclosures made to you; (3) disclosures made pursuant to your authorization; (4) disclosures made to friends or family in your presence or because of an emergency; (5) disclosures for national security purposes; and (6) disclosures incidental to otherwise permissible disclosures.

To request this list or accounting of disclosures, you must submit your request in writing. Your request must state the time period you want the accounting to cover, which may not be longer than six years before the date of the request. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be provided free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on your PHI that we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on your PHI that we disclose to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery that you had.

Except as provided in the next paragraph, we are not required to agree to your request. However, if we do agree to the request, we will honor the restriction until you revoke it or we notify you.

We will comply with any restriction request if (1) except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and (2) the PHI pertains solely to a health care item or service for which the health care provider involved has been paid in full by you or another person.

To request restrictions, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply-for example, disclosures to your spouse.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests.

Right to Be Notified of a Breach. You have the right to be notified in the event that we (or a Business Associate) discover a breach of unsecured PHI.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

IX. Complaints

If you believe that your privacy rights have been violated, you may file a complaint with the Plan or with the Office for Civil Rights of the United States Department of Health and Human Services. To file a complaint with the Plan, contact the person listed in the Contact Information section of this Notice. All complaints must be submitted in writing. You will not be penalized, or in any other way retaliated against, for filing a complaint with the Office for Civil Rights or with us.

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.

Alabama – Medicaid

Website: http://www.myalhipp.com/ Phone: 1-855-692-5447

Alaska – Medicaid

The AK Health Insurance Premium Payment Program Website: http:// myakhipp.com/ Phone: 1-866-251-4861

Email: CustomerService@MyAKHIPP.com

Medicaid Eligibility: https://health.alaska. gov/dpa/Pages/default.aspx

Arkansas – Medicaid

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

California– Medicaid

Health Insurance Premium Payment (HIPP) Program Website: http://dhcs. ca.gov/hipp

Phone: 916-445-8322

Fax: 916-440-5676

Email: hipp@dhcs.ca.gov

Colorado – Health First Colorado (Colorado’s Medicaid Program) and Child Health Plan Plus (CHP+)

Health First Colorado website: https:// www.healthfirstcolorado.com/

Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711

CHP+: https://hcpf.colorado.gov/childhealth-plan-plus

CHP+ Customer Service: 1-800-3591991/State Relay 711

Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442

Florida – Medicaid

Website: https://www. flmedicaidtplrecovery.com/ flmedicaidtplrecovery.com/hipp/index. html

Phone: 1-877-357-3268

Georgia – Medicaid

GA HIPP Website: https://medicaid. georgia.gov/health-insurance-premiumpayment-program-hipp

Phone: 678-564-1162, Press 1

GA CHIPRA Website: https://medicaid. georgia.gov/programs/third-partyliability/childrens-health-insuranceprogram-reauthorization-act-2009chipra

Phone: 678-564-1162, Press 2

Indiana

– Medicaid

Health Insurance Premium Payment Program

All other Medicaid

Website: https://www.in.gov/medicaid/ http://www.in.gov/fssa/dfr/ Family and Social Services Administration

Phone: 1-800-403-0864

Member Services Phone: 1-800-4574584

Iowa – Medicaid and CHIP (Hawki)

Medicaid Website: https://hhs.iowa.gov/ programs/welcome-iowa-medicaid

Medicaid Phone: 1-800-338-8366

Hawki Website: https://hhs.iowa.gov/ programs/welcome-iowa-medicaid/ iowa-health-link/hawki

Hawki Phone: 1-800-257-8563

HIPP Website: https://hhs.iowa.gov/ programs/welcome-iowa-medicaid/feeservice/hipp

HIPP Phone: 1-888-346-9562

Kansas – Medicaid

Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884

HIPP Phone: 1-800-967-4660

Kentucky – Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP)

Website: https://chfs.ky.gov/agencies/ dms/member/Pages/kihipp.aspx

Phone: 1-855-459-6328

Email: KIHIPP.PROGRAM@ky.gov

KCHIP Website: https://kynect.ky.gov Phone: 1-877-524-4718

Kentucky Medicaid Website: https://chfs. ky.gov/agencies/dms

Louisiana – Medicaid

Louisiana Medicaid Website: https:// www.ldh.la.gov/healthy-louisiana Medicaid Customer Service Line: 1-888342-6207

Louisiana Medicaid email: healthy@ la.gov

Louisiana Health Insurance Premium Program (LaHIPP) Website: https://www. ldh.la.gov/lahipp

LaHIPP phone: 1-877-697-6703

LaHIPP email: La.HIPP@la.gov

LaHIPP fax: 1-888-716-9787

LaHIPP mailing address: 100 Crescent Centre Parkway, Suite 1000 Tucker, GA 30084

Maine – Medicaid

Enrollment Website: https://www. mymaineconnection.gov/benefits/ s/?language=en_US

Phone: 1-800-442-6003

TTY: Maine relay 711

Private Health Insurance Premium

Webpage: https://www.maine.gov/dhhs/ ofi/applications-forms

Phone: 1-800-977-6740

TTY: Maine Relay 711

Massachusetts – Medicaid and CHIP

Website: https://www.mass.gov/ masshealth/pa

Phone: 1-800-862-4840

TTY: 711

Email: masspremassistance@accenture. com

Minnesota – Medicaid

Website: https://mn.gov/dhs/healthcare-coverage/

Phone: 1-800-657-3672

Missouri – Medicaid

Website: http://www.dss.mo.gov/mhd/ participants/pages/hipp.htm

Phone: 573-751-2005

Montana – Medicaid

Website: https://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084

Email: HHSHIPPProgram@mt.gov

Nebraska – Medicaid

Website: http://www.ACCESSNebraska. ne.gov

Phone: 1-855-632-7633

Lincoln: 402-473-7000

Omaha: 402-595-1178

Nevada – Medicaid

Medicaid Website: http://dhcfp.nv.gov

Medicaid Phone: 1-800-992-0900

New Hampshire – Medicaid

Website: https://www.dhhs.nh.gov/ programs-services/medicaid/healthinsurance-premium-program

Phone: 603-271-5218

Toll free number for the HIPP program: 1-800-852-3345, ext. 15218

Email: DHHS.ThirdPartyLiabi@dhhs. nh.gov

New Jersey – Medicaid and CHIP

Medicaid Website: http://www.state. nj.us/humanservices/dmahs/clients/ medicaid/ Phone: 1-800-356-1561

CHIP Premium Assistance Phone: 609631-2392

CHIP Website: http://www.njfamilycare. org/index.html

CHIP Phone: 1-800-701-0710 (TTY: 711)

New York – Medicaid

Website: https://www.health.ny.gov/ health_care/medicaid/ Phone: 1-800-541-2831

North Carolina – Medicaid

Website: https://medicaid.ncdhhs.gov Phone: 919-855-4100

North Dakota – Medicaid

Website: https://www.hhs.nd.gov/ healthcare Phone: 1-844-854-4825

Oklahoma – Medicaid and CHIP

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

Oregon – Medicaid

Website: https://healthcare.oregon.gov/ Pages/index.aspx

Phone: 1-800-699-9075

Pennsylvania – Medicaid and CHIP

Website: https://www.pa.gov/en/ services/dhs/apply-for-medicaid-healthinsurance-premium-payment-programhipp.html

Phone: 1-800-692-7462

CHIP Website: https://www.dhs.pa.gov/ chip/pages/chip.aspx

CHIP Phone: 1-800-986-KIDS (5437)

Rhode Island – Medicaid and CHIP

Website: http://www.eohhs.ri.gov/

Phone: 1-855-697-4347 or 401-462-0311

(Direct RIte Share Line)

South Carolina – Medicaid

Website: https://www.scdhhs.gov

Phone: 1-888-549-0820

South Dakota - Medicaid

Website: https://dss.sd.gov

Phone: 1-888-828-0059

Texas – Medicaid

Website: https://www.hhs.texas.gov/ services/financial/health-insurancepremium-payment-hipp-program

Phone: 1-800-440-0493

Utah – Medicaid and CHIP

Utah’s Premium Partnership for Health Insurance (UPP) Website: https:// medicaid.utah.gov/upp/ Email: upp@utah.gov Phone: 1-888-222-2542

Adult Expansion Website: https:// medicaid.utah.gov/expansion/ Utah Medicaid Buyout Program Website: https://medicaid.utah.gov/buyoutprogram/

CHIP Website: https://chip.utah.gov/ Vermont– Medicaid

Website: https://dvha.vermont.gov/ members/medicaid/hipp-program Phone: 1-800-250-8427

Virginia – Medicaid and CHIP

Website: https://coverva.dmas.virginia. gov/learn/premium-assistance/famisselect https://coverva.dmas.virginia.gov/learn/ premium-assistance/health-insurancepremium-payment-hipp-programs Medicaid/CHIP Phone: 1-800-432-5924

Washington – Medicaid

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

West Virginia – Medicaid and CHIP

Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700

CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699- 8447)

Wisconsin – Medicaid and CHIP

Website: https://www.dhs.wisconsin.gov/ badgercareplus/p-10095.htm Phone: 1-800-362-3002

Wyoming – Medicaid

Website: https://health.wyo.gov/ healthcarefin/medicaid/programs-andeligibility/ Phone: 1-800-251-1269

To see if any other States have added a premium assistance program since January 31, 2026, or for more information on special enrollment rights, 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 MB2 Dental, PLLC group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the MB2 Dental, PLLC 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

MB2 Dental, PLLC Human Resources 2403 Lacy Lane Carrollton, TX 75006 972-869-3789 ext. 194

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 outof-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-of-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 in-network costs for the same service and might not count toward your annual out-ofpocket 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-ofnetwork provider.

You are protected from balance billing for:

’ Emergency services – If you have an emergency medical condition and get emergency services from an out-ofnetwork provider or facility, the most the provider or facility may bill you is your plan’s in-network 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 innetwork 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 innetwork 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 out-ofnetwork. 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 out-of-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 (cost-sharing) 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-ofnetwork 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-ofpocket 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 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 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 1-800318-2596. TTY users can call 1-855-8894325

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 employer-sponsored 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 employmentbased 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/gettingmedicaid-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: MB2 Dental, PLLC

4. Employer Identification Number (EIN): 26-4287971

5. Employer Address: 2403 Lacy Lane

6. Employer Phone Number: 972-869-3789, EXT 194

7. City: Carrollton

8. State: TX 9. ZIP Code: 75006

10. Who can we contact at this job?: Chad Caldwell

11. Phone Number (if different from above): N/A

12. E-Mail Address: benefits@mb2dental.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 employmentbased 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 MB2 Dental Solutions, PLLC employee benefits program. 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. MB2 Dental Solutions, PLLC reserves the right to change or discontinue its employee benefits plans anytime.