HELPFUL RESOURCES
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 April 1, 2026.
Each year during Open Enrollment (OE), you may make changes to your benefit plans. The benefit choices you make this year will remain in effect through March 31, 2027. Take time to review these benefit options and select the plans that best meet your needs. After OE, you may only make changes to your benefit elections if you have a Qualifying Life Event (QLE).
Availability of Summary Health Information
Your benefits program offers two medical coverage options. To help you make an informed choice and compare your options, a Summary of Benefits and Coverage for each plan is available at www.myuhc.com or by calling 877-797-8812
ELIGIBILITY
You are eligible for benefits if you are a regular, full-time employee working an average of 30 hours per week. Your coverage is effective after 90 days of continuous employment. 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 Include
f Your legal spouse
f Children under the age of 26 regardless of student, dependency, or marital status
f 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 OE. You may only change coverage during the plan year if you have a QLE, some of which include:
f Marriage, divorce, legal separation, or annulment
f Birth, adoption, or placement for adoption of an eligible child
f Death of your spouse or child
f Change in your spouse’s employment status that affects benefits eligibility
f Change in your child’s eligibility for benefits
f Significant change in benefit plan coverage for you, your spouse, or child
f FMLA leave, COBRA event, court judgment or decree
f Becoming eligible for Medicare, Medicaid, or TRICARE
f Receiving a Qualified Medical Child Support Order
If you have a QLE and want to change your elections, you must notify Human Resources and complete your changes within 30 days of the event. You may be asked to provide documentation to support the change. Contact Human Resources for specific details.
HOW TO ENROLL
Go to www.benefitsinhand.com
(First-time users follow steps 2-5. Returning users log in and start at step 6.)
If this is your very first time to log in, click on the New User Registration link.
Once you register, you will just use your username and password to log in.
1. Enter your personal information and company identifier of PalCare and click Next.
2. Create a username (work email address recommended) and Password and then check “I agree to terms and conditions” before you click Finish.
3. 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.
Employee Response Center
Employee benefits can be complicated. The Higginbotham Employee Response Center can assist you with the following:
f Enrollment
f Benefits information
f Claims or billing questions
f 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 voicemail message after 3:00 p.m. CT, your call will be returned the next business day. You can also email questions or requests to helpline@higginbotham.net.
4. Click the Start Enrollment button to begin the enrollment process.
5. Confirm or update your personal information and click Save & Continue
6. Edit dependents or add dependents that you will be enrolling in benefits. Once all dependents are listed click Save & Continue
7. Follow the steps on the screen for each benefit to make your selection. Please notice there is an option to decline coverage. If you want to decline, click the “Don’t want this benefit? ” button and select the reason you are declining.
8. Once you have elected or declined all benefits you will see a summary of your selections. Click the Click to Sign button. Your Enrollment is not complete until you click the Click to Sign button.
MEDICAL COVERAGE
The medical plan options through UnitedHealthcare (UHC) protect you and your family from major financial hardship in the event of illness or injury. You have a choice of two plans:
f Base Plan – This plan is an HDHP, with a $3,400 individual and a $6,800 family in-network deductible
f Buy-Up Plan – This plan is a PPO, with a $1,000 individual and a $2,000 family in-network deductible
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 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 innetwork providers, your office visits, urgent care visits, and prescription drugs are covered with a copay, and most other network services are covered at the deductible and 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 14).
Mobile App
The UnitedHealthcare app gives you a simple way to personalize, organize, and access your family’s important health information – on the go. It helps put you in control of your health. You will have immediate access to the following features:
f Find a doctor
f Access claims information
f Get medical ID card information
f Review benefit information
f And more
GoodRx
Prescription drug prices are not regulated and can vary greatly between pharmacies. GoodRx allows you to view prices and find coupons, discounts, and savings tips. Visit www.goodrx.com to print coupons, or download the GoodRx app to display coupons on your phone. You can also search for your prescription and compare prices at nearby pharmacies.
f Compare prescription drug prices
f Receive coupons, discounts and savings tips for pharmacies near you
f Print coupons online or view from the mobile app
GoodRx is a free service, so you do not have to create an account to search for prices and receive discounts. If you do create an account, you can store your prescription list for ease of use in the future.
Medical Plan Comparison
TELEMEDICINE
Your medical coverage offers telemedicine services through HealthiestYou . Connect anytime day or night with a boardcertified doctor via your mobile device or computer for free
While telemedicine does not replace your primary care physician, it is a convenient and cost-effective option when you need care.
WHEN TO USE HEALTHIEST YOU
Use telemedicine services for minor conditions such as:
• Sore throat
• Headache
• Earache
• Fever
• Cold/Flu
• Bronchitis
• Allergies
• Stomachache
• Urinary tract infection
• Pink eye
• Rashes
• Addictions
• Bipolar disorders
• Depression
• Eating disorders
• Grief/Loss
• Panic disorders
• Parenting issues
• Postpartum depression
• Stress
• Trauma/PTSD
• Acne
• Eczema
• Shingles
• Psoriasis
• And more
Do not use telemedicine for serious or life-threatening emergencies.
Your cost: $0
• Relieve your back and neck pain through guided videos with a certified health coach
Registration is Easy
Register for an account so you are ready to use this valuable service when and where you need it.
f Visit – https://uhc.healthiestyou.com/#lpcode-392%22uhc.healthiestyou.com/#lpcode-392
f HealthiestYou customer care – 866-703-1259
f Medical Services – 866-904-0910
f Mobile – download the HealthiestYou app
HEALTH CARE OPTIONS
Becoming familiar with your options for medical care can save you time and money.
NON-EMERGENCY
Access to care via phone, online video, or mobile app whether you are home, work, or traveling; medications can be prescribed
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
HOSPITAL ER
FREESTANDING ER
Life-threatening or critical conditions; trauma treatment; multiple bills for doctor and facility
24 hours a day, 7 days a week
Services do not include trauma care; can look similar to an urgent care center, but medical bills may be 10 times higher
24 hours a day, 7 days a week
Allergies
Cough/cold/flu
Rash
Stomachache
Infections
Sore and strep throat
Vaccinations
Minor injuries/sprains/ strains
Common infections
Minor injuries
Pregnancy tests
Vaccinations
Sprains and strains
Minor broken bones
Small cuts that may require stitches
Minor burns and infections
EMERGENCY CARE
Chest pain
Difficulty breathing
Severe bleeding
Blurred or sudden loss of vision
Major broken bones
Most major injuries except trauma
Severe pain
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.
UHC WELLNESS PROGRAMS
Rally
Learning to live healthy is easier when you have help finding your way. The Rally website and mobile app help you learn simple ways to take care of yourself — from being more active to eating better. When you make small changes and add healthy habits to your everyday life, you move toward better health management, which helps you live a full, active life.
Rally makes it easy to make small changes, one step at a time. Get started and you will get a customized program designed to help you live healthier.
f See Your Rally Age – Take a health survey to see your Rally age, a measure of your overall health.
f Accept Your Missions – Receive a list of easy, fun missions based on your Rally age, each designed to help you eat better, lift your fitness level, and improve your mood.
f Take On a Challenge – Use the Rally app to track your activity and compete with other Rally members to earn extra rewards.
f Connect with a Coach – Talk with a coach and work together to create a personalized healthy-living plan that works with your lifestyle.
Visit - www.myuhc.com to sign up.
Mobile – Download the Rally app.
Employee Assistance Program
The Employee Assistance Program (EAP) from UHC 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:
f Relationships
f Work-life balance
f Stress and anxiety
f Will preparation and estate resolution
f Grief and loss
f Childcare and eldercare resources
f Substance abuse Call 888-887-4114 for support at any hour of the day or night.
UHC WELLNESS PROGRAMS
Real Appeal
Real Appeal is a free digital program that provides up to a full year of support for lasting weight loss, including:
f A personal transformation coach to offer step-by-step guidance and customization for a program that fits your needs, preferences and goals
f 24/7 convenience through online access to food, activity and goal trackers, group classes, and expert health tips
f A Success Kit to help kick-start your weight loss journey and keep you on the road to results Visit https://realappeal.com/ to get started.
DENTAL COVERAGE
Our dental plan helps 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 out-of-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.
DENTAL PLAN
Rollover Benefit
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 Benefit for each insured person in a given calendar year, increasing the following Policy Year maximum for that insured person (subject to certain conditions).
Rollover calculations are determined based on innetwork provisions.
* Calendar year is January 1 – December 31. Your calendar year deductible and benefit maximum will reset to $0 every January 1.
** See your plan for details about out-of-network coverage. Out-of-network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of: the dentist’s actual charge (the ‘Actual Charge’), the dentist’s usual charge for the same or similar services (the ‘Usual Charge’), or the usual charge of most dentists in the same geographic area for the same or similar services as determined by Mutual of Omaha (the ‘Customary Charge’). For your plan, the Customary Charge is based on the 90th percentile. Services must be necessary in terms of generally accepted dental standards.
Find an In-Network Dentist
f Visit – www.mutualofomaha.com/dental
f Call – 800-927-9197
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 an in-network provider. Coverage is provided through Mutual of Omaha
Find an In-Network Vision Provider
Visit www.mutualofomaha.com/vision or call 833279-4358
• Single Vision
• Bifocals
• Trifocals
• Lenticular
• Progressive $25 copay $25 copay $25 copay $25 copay
Contacts
In lieu of frames and lenses
• Elective
• Medically
copay
Once every 12 months
Once every 12 months
Once every 24 months
Once every 12 months
Hearing Discount Program
The program provides you and your family discounted hearing products, including hearing aids and batteries. Call 888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more.
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:
f Enrolled in an HSA-eligible HDHP (Base Plan)
f Not covered by another plan that is not a qualified HDHP, such as your spouse’s health plan
f Not enrolled in a Health Care Flexible Spending Account
f Not eligible to be claimed as a dependent on someone else’s tax return
f Not enrolled in Medicare, Medicaid, or TRICARE
f 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.
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
f 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.
f You, not your employer, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit.
f 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.
Maximum Contributions
Your HSA contributions may not exceed the annual maximum amount established by the IRS. PalCare contributes to HSA.
MAXIMUM EMPLOYEE CONTRIBUTION FOR 2026 (LESS THE EMPLOYER CONTRIBUTION)
$4,400-$900 = $3,750 total contribution
$8,500-$1,800= $6,950 total contribution
The annual contribution maximum is based on the coverage option you elect:
f Individual – $4,400
f Family (filing jointly) – $8,750
You decide whether to use the money in your account to pay for qualified expenses or let it grow for future use. If you turn age 55 at anytime during the plan year, you are eligible to make the catch-up contribution for the entire plan year.
ABBREVIATED LIST OF QUALIFIED HSA EXPENSES
The products and services listed below are examples of medical expenses eligible for payment under your Health Care HSA. This list is not all-inclusive; additional expenses may qualify and the items listed are subject to change in accordance with IRS regulations. Please refer to IRS Publication 502 Medical and Dental Expenses at www.irs.gov for a complete description of eligible medical and dental expenses.
f Abdominal supports
f Acupuncture
f Air conditioner (when necessary for relief from difficulty in breathing)
f Alcoholism treatment
f Ambulance
f Anesthetist
f Arch supports
f Artificial limbs
f Autoette (when used for relief of sickness/disability)
f Blood tests
f Blood transfusions
f Braces
f Cardiographs
f Chiropractor
f Contact lenses
f Convalescent home (for medical treatment only)
f Crutches
f Dental treatment
f Dental X-rays
f Dentures
f Dermatologist
f Diagnostic fees
f Diathermy
f Drug addiction therapy
f Drugs (prescription)
f Elastic hosiery (prescription)
f Eyeglasses
f Fees paid to health institute prescribed by a doctor
f FICA and FUTA tax paid for medical care service
f Fluoridation unit
f Guide dog
f Gum treatment
f Gynecologist
f Healing services
f Hearing aids and batteries
f Hospital bills
f Hydrotherapy
f Insulin treatment
f Lab tests
f Lead paint removal
f Legal fees
f Lodging (away from home for outpatient care)
f Metabolism tests
f Neurologist
f Nursing (including board and meals)
f Obstetrician
f Operating room costs
f Ophthalmologist
f Optician
f Optometrist
f Oral surgery
f Organ transplant (including donor’s expenses)
f Orthopedic shoes
f Orthopedist
f Osteopath
f Oxygen and oxygen equipment
f Pediatrician
f Physician
f Physiotherapist
f Podiatrist
f Postnatal treatments
f Practical nurse for medical services
f Prenatal care
f Prescription medicines
f Psychiatrist
f Psychoanalyst
f Psychologist
f Psychotherapy
f Radium therapy
f Registered nurse
f Special school costs for the handicapped
f Spinal fluid test
f Splints
f Surgeon
f Telephone or TV equipment to assist the hard-of-hearing
f Therapy equipment
f Transportation expenses (relative to health care)
f Ultraviolet ray treatment
f Vaccines
f Vitamins (if prescribed)
f Wheelchair
f X-rays
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 35% at age 70, and 50% at age 75.
Basic Life and AD&D
Basic Life and AD&D insurance are provided at no cost to you. You are automatically covered at $25,000 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. 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.
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%).
(age 15-69)
• Increments of $5,000 up to $150,000 (not to exceed 50% of employee amount)
(age 15-69)
Cost Example
John is 45 years old and elects $100,000 of coverage
$ /1000 × = $ × 12 = $
$100,000/1000 x Rate = Monthly Cost x 12/26 = Per pay cost
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) insurance for you to purchase through Mutual of Omaha. Long Term Disability (LTD) is provided to you at no cost.
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-work-related injury. STD benefits are not payable if the disability is due to a job-related injury or illness. If a medical condition is jobrelated, it is considered workers' compensation, not STD.
Long Term Disability
LTD 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, up to age 65 standard Age Discrimination in Employment Act (ADEA). Employer pays for LTD at no cost to the member.
LONG TERM DISABILITY
You
Benefit Period 12 weeks
Pre-existing Condition Exclusion 3/6*
*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.
SHORT-TERM DISABILITY COST EXAMPLE
John earns $50,000 annually
$50,000 / 52 = $962 Weekly Earnings
$962 × 60% = $577 Monthly Benefit
$577 × $0.34 = $98.12 / 10 = $19.62 Monthly Cost
Benefit Period To age 65 standard ADEA
Pre-existing Condition Exclusion 3/12*
*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. STD Rate Per $10 of Weekly Benefit: $0.34
SUPPLEMENTAL INSURANCE
You and your eligible family members have the opportunity to enroll in additional coverage that complements our traditional health care programs. Health insurance covers medical bills, but if you have an emergency, you may face unexpected out-of-pocket costs such as deductibles, coinsurance, travel expenses, and non-medical expenses. Coverage is provided through Mutual of Omaha
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, deductibles, ambulance, physical therapy, childcare, rent, and other costs not covered by traditional health plans. The chart below shows only some of the benefits available. See the plan document for full details.
Hospital 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. Unlike traditional insurance, which pays a benefit to the hospital or doctor, this plan pays you directly. It is up to you how you want to use the cash benefit. These costs may include meals, travel, childcare or eldercare, deductibles, coinsurance, medication, or time away from work. The chart below shows only some of the benefits available. See the plan document for full details.
Specific Sum Injuries
Dislocations, ruptured discs, eye injuries, fractures, lacerations, concussions, etc.
•
ADDITIONAL BENEFITS
As part of your Mutual of Omaha Life or Disability Plan membership, you have access to the programs described below at no additional cost.
Will Preparation
Creating a will is an essential part of estate planning. While many people recognize the importance of purchasing life insurance, less than 50 percent have a legal will. Get free, online will preparation services to help protect your family’s future. Log on to www.willprepservices.com (registration code MUTUALWILLS) for details.
Worldwide Travel Assistance
If you and your family are traveling more than a 100 miles away from home, you have access to worldwide emergency travel assistance. Services range from pre-trip planning, medical emergency support, translation services, lost luggage or passport assistance, emergency cash, and more. Services must be coordinated through Worldwide Travel Assistance to be covered.
Contact Worldwide Travel Assistance
f In the U.S. – 800-856-9947
f Outside the U.S. – 312-935-3658
Employee Assistance Program
The Employee Assistance Program (EAP) from Mutual of Omaha helps you and family members cope with a variety of personal or work-related issues. This program provides 24/7/365 confidential counseling and support services at little or no cost to you to help with:
f Relationships
f Work/life balance
f Stress and anxiety
f Will preparation and estate resolution
f Grief and loss
f Childcare and eldercare resources
f Substance abuse
f Family legal services
f Family financial services
f And more
Full-time employees and their immediate family members
– including the employee, spouse, and dependent children (unmarried and under 26) who reside with the employee –are eligible to use the EAP.
f Visit – www.mutualofomaha.com/eap
f Call – 800-316-2796
f 24/7/365 access and support
f Three free counseling sessions per incident, per year (either in-person or virtual)
f Confidential and private
2026-2027 Holiday Schedule
DAY
HOLIDAY
Friday, April 3, 2026 Good Friday
Monday, May 25, 2026 Memorial Day
Saturday, July 4, 2026 Independence Day
Monday, September 7, 2026 Labor Day
Thursday, November 26, 2026 Thanksgiving Day
Friday, November 27, 2026 Black Friday
Thursday, December 24, 2026 Christmas Eve (observed)
Friday, December 25, 2026 Christmas Day (observed)
Friday, January 1, 2027
2027 New Year’s Day (observed)
EMPLOYEE CONTRIBUTIONS
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:
Palatmiumcare, Inc. dba PalCare Human Resources 909 N 8th St. 201 Sheboygan, WI 53081
773-497-8803
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 Palatmiumcare, Inc. dba PalCare 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.
LEGAL NOTICES
2. Palatmiumcare, Inc. dba PalCare has determined that the prescription drug coverage offered by the Palatmiumcare, Inc. dba PalCare 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 not 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 Palatmiumcare, Inc. dba PalCare 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 Palatmiumcare, Inc. dba PalCare 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 888-7252848.
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
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 01, 2026
Palatmiumcare, Inc. dba PalCare Human Resources
909 N 8th St. 201 Sheboygan, WI 53081 773-497-8803
LEGAL NOTICES
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 Palatmiumcare, Inc. dba PalCare 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:
Palatmiumcare, Inc. dba PalCare Human Resources 909 N 8th St. 201 Sheboygan, WI 53081 773-497-8803
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
LEGAL NOTICES
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.
LEGAL NOTICES
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:
1. The individual identifiers have been removed; or
2. 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.
LEGAL NOTICES
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.
LEGAL NOTICES
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.
LEGAL NOTICES
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: 1-800-2213943/State Relay 711
CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/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/healthinsurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1
GA CHIPRA Website: https://medicaid.georgia.gov/programs/ third-party-liability/childrens-health-insurance-programreauthorization-act-2009-chipra
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: 1-800-457-4584
LEGAL NOTICES
Iowa – Medicaid and CHIP (Hawki)
Medicaid Website: https://hhs.iowa.gov/programs/welcomeiowa-medicaid
Medicaid Phone: 1-800-338-8366
Hawki Website: https://hhs.iowa.gov/programs/welcomeiowa-medicaid/iowa-health-link/hawki
Hawki Phone: 1-800-257-8563
HIPP Website: https://hhs.iowa.gov/programs/welcomeiowa-medicaid/fee-service/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/healthylouisiana
Medicaid Customer Service Line: 1-888-342-6207
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/health-care-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/health-insurance-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: 609-631-2392
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
LEGAL NOTICES
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-formedicaid-health-insurance-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-insurance-premium-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/buyout-program/ CHIP Website: https://chip.utah.gov/
Vermont– Medicaid
Website: https://dvha.vermont.gov/members/medicaid/hippprogram
Phone: 1-800-250-8427
Virginia – Medicaid and CHIP
Website: https://coverva.dmas.virginia.gov/learn/premiumassistance/famis-select https://coverva.dmas.virginia.gov/learn/premium-assistance/ health-insurance-premium-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-and-eligibility/ 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 Palatmiumcare, Inc. dba PalCare group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the Palatmiumcare, Inc. dba PalCare 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.
LEGAL NOTICES
Plan Contact Information
Palatmiumcare, Inc. dba PalCare Human Resources
909 N 8th St. 201 Sheboygan, WI 53081 773-497-8803
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-ofnetwork providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
• 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, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections. You are never required to give up your protections from balance billing. You also are not required to get care outof-network. You can choose a provider or facility in your plan’s network.
When balance billing is not allowed, you also have the following protections:
• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay outof-network providers and facilities directly.
• Your health plan generally must:
• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (costsharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
LEGAL NOTICES
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 employmentbased coverage. Also, this employer contribution -as well as your employee contribution to employmentbased coverage- is generally excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. In addition, note that if the health coverage offered through your employment does not meet the affordability or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You should consider all of these factors in determining whether to purchase a health plan through the Marketplace.
When Can I Enroll in Health Insurance Coverage through the Marketplace?
You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period. Open Enrollment varies by state but generally starts November 1 and continues through at least December 15. Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment Period. In general, you qualify for a Special Enrollment Period if you’ve had certain qualifying life events, such as getting married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the qualifying life event to enroll in a Marketplace plan. There is also a Marketplace Special Enrollment Period for individuals and their families who lose eligibility for Medicaid or Children’s Health Insurance Program (CHIP)
LEGAL NOTICES
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.
LEGAL NOTICES
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: Palatmiumcare, Inc. dba PalCare
5. Employer Address: 909 N 8th St. 201
7. City: Sheboygan
4. Employer Identification Number (EIN): 20-0005910
6. Employer Phone Number: 773-497-8803
8. State: WI 9. ZIP Code: 53081
10. Who can we contact at this job?: Alex Thornton
11. Phone Number (if different from above):
12. E-Mail Address: athornton@palcare.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 PalCare 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. PalCare reserves the right to change or discontinue its benefits plans at anytime.
