2026
IMPORTANT CONTACTS
We are pleased to offer a full benefits package to help protect your wellbeing and financial health. Read this guide to learn about the benefits available to you and your eligible dependents.
Each year during Open Enrollment, you may make changes to your benefit plans. The benefit choices you make this year will remain in effect from January 1, 2026 through December 31, 2026. Take time to review these benefit options and select the plans that best meet your needs. After Open Enrollment, you may only make changes to your benefit elections if you have a Qualifying Life Event.
Availability of Summary Health Information
To help you make an informed choice and compare your options, a Summary of Benefits and Coverage (SBC) is available on Employee Navigator or by contacting Human Resources.
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices for your prescription drug coverage. Please see page 19 for more details.
ELIGIBILITY
You are eligible for benefits if you are an active, full-time employee working an average of 30 or more hours per week. If you are a new hire, your coverage will be effective on the first of the month following 30 days of 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
z Your legal spouse
z Children under the age of 26 regardless of student, dependency or marital status
z Children over the age of 26 who are fully dependent on you for support due to a mental or physical disability and who are indicated as such on your federal tax return
Qualifying Life Events
Once you elect your benefit options, they remain in effect for the entire plan year until the following Open Enrollment. You may only change coverage during the plan year if you have a Qualifying Life Event, some of which include:
z Marriage, divorce, legal separation, or annulment
z Birth, adoption, or placement for adoption of an eligible child
z Death of your spouse or child
z Change in your spouse’s employment status that affects benefits eligibility
z Change in your child’s eligibility for benefits
z Significant change in benefit plan coverage for you, your spouse, or your child
z FMLA leave, COBRA event, court judgment, or decree
z Becoming eligible for Medicare, Medicaid, or TRICARE
z Receiving a Qualified Medical Child Support Order
If you have a Qualifying Life Event and want to change your elections, you must notify Human Resources and complete your changes in Employee Navigator within 30 days of the event. You may be asked to provide documentation to support the change. Contact Human Resources for specific details.
EMPLOYEE RESPONSE CENTER
Employee benefits can be complicated. The Higginbotham Employee Response Center can assist you with the following:
Call or text 833-987-2264 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. You can also email questions or requests to clarkcommunitymentalhealth@eb.higginbotham.net. Bilingual representatives are available.
EMPLOYEE NAVIGATOR
Online Enrollment Instructions
To begin the enrollment process, go to www.employeenavigator.com. Firsttime users, follow steps 1-4. Returning users, log in and start at step 5.
1. If this is your first time to log in, click on the New User Registration link. Once you register, you will use your username and password to log in.
2. Enter your personal information and company identifier of CCMHC and click Next.
3. Create a username (work email address recommended) and password, then check the I agree to terms and conditions box before you click Finish.
4. If you used an email address as your username, you will receive a validation email to that address. You may now log in to the system.
5. Click the Start Enrollment button to begin the enrollment process.
6. Confirm or update your personal information and click Save & Continue.
7. Edit or add dependents who need to be covered on your benefits. Once all dependents are listed, click Save & Continue.
8. Follow the steps on the screen for each benefit to make your election. Please notice there is an option to decline coverage. If you wish to decline, click the Don’t want this benefit? button and select the reason for declining.
9. Once you have elected or declined all benefits, you will see a summary of your elections. Click the Click to Sign button. Your enrollment will not be complete until you click the Click to Sign button.
Have questions about your benefits or need help enrolling? Call or text the Employee Response Center at 833-987-2264. Benefits experts are available to take your call or text Monday through Friday from 7:00 a.m. to 6:00 p.m. CT.
MEDICAL COVERAGE
The medical plan options through Cox HealthPlans protect you and your family from major financial hardship in the event of illness or injury.
z Partners 80 – This plan is a PPO.
Preferred Provider Organization
HealthPlans Visit www.coxhealthplans.com or call 417-269-2900
First Health Network
Visit www.coxhealthplans.com or call 800-226-5116, option 1
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 in-network providers, your office visits, urgent care visits, and prescription drugs are covered with a copay and most other in-network services are covered at the deductible and coinsurance level. In the Southwest Missouri area, Cox Health hospitals and clinics, along with Freeman in Joplin, are in-network. Outside of the Southwest Missouri area, please utilize providers in the First Health Network for in-network care.
HEALTH CARE OPTIONS
Becoming familiar with your options for medical care can save you time and money.
Non-Emergency Care
Access to care via phone, online video or mobile app whether you are home, work or traveling; medications can be prescribed
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
Emergency Care
HOSPITAL ER
FREESTANDING ER
Generally includes evening, weekend and holiday hours
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 and strains
• Common infections
• Minor injuries
• Pregnancy tests
• Vaccinations
• Sprains and strains
• Minor broken bones
• Small cuts that may require stitches
• Minor burns and infections
• Chest pain
• Difficulty breathing
• Severe bleeding
• Blurred or sudden loss of vision
• Major broken bones
• Most major injuries except trauma
• Severe pain
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.
TELEMEDICINE
Your medical coverage offers telemedicine services through Cox Health. While telemedicine does not replace your primary care physician, it is a convenient and costeffective 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
Registration is Easy
Register so you are ready to use this valuable service when and where you need it.
z Online – www.coxhealth.com/services/virtualvisits-2
z Phone – 417-269-8633
Hours
Monday through Friday, 8:00 a.m. – 8:00 p.m.
WHEN TO USE TELEMEDICINE
Use telemedicine services for minor conditions such as:
z Sore throat
z Headache
z Stomachache
z Cold/Flu
z Mental health issues
z Allergies
z Fever
z Urinary tract infections
Do not use telemedicine for serious or life-threatening emergencies.
Primary care physician and Specialists cost: $10
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 Principal
Note: For extensive dental work, prior authorization is recommended.
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.
Maximum Accumulation Account
If you are a dental plan member, you will be automatically enrolled in the Principal Maximum Accumulation Account (MAA) program. When you have regular dental checkups, and your yearly claims are below the $500 threshold, Principal will carry over a portion of your unused annual maximum into your personal MAA. Your MAA can be used in future years if you reach the plan’s annual maximum. If you have at least $500 in your current year annual maximum benefit, Principal will carry over $250 into your MAA. Leftover award balances carry over to the next benefit period. Once your account reaches $1,000, no additional funds will be placed in your MAA. You and your insured dependents maintain separate MAAs based on individual activity. The entire accumulation amount will be forfeited if you receive no dental services during the calendar year.
1Payment for covered services received from an out-of-network dentist is based on the 90th percentile of Usual, Customary and Reasonable (UCR) charges.
2The amount you pay after the deductible has been met.
Refer to the Principal Dental Patient Charge schedule for details.
Visit www.principal.com/dentist or call 800-986-3343.
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 Principal using the VSP Choice network.
Note: When seeing an out-of-network provider, members are responsible for requesting reimbursement.
Lenses (in lieu of eyeglasses)
• Fitting and Evaluation
• Elective
• Necessary
FLEXIBLE SPENDING ACCOUNTS
How the Health Care FSA Works
You can access the funds in your Health Care FSA two different ways:
z Use your FSA debit card to pay for qualified expenses, doctor visits and prescription copays.
z Pay out-of-pocket and submit your receipts for reimbursement:
• Phone –800-422-4661
• Online – www.tasconline.com
Important FSA Rules
z The maximum per plan year you can contribute to a Health Care FSA is $3,400 (including Clark Community Mental Health’s $500 annual contribution). The maximum per plan year you can contribute to a Dependent Care FSA is $7,500 when filing jointly or head of household and $3,750 when married filing separately.
z You cannot change your election during the year unless you experience a Qualifying Life Event.
z You can continue to file claims incurred during the plan year for another 60 days (February 28, 2027).
z Your Health Care FSA debit card can be used for eligible health care expenses only. It cannot be used to pay for dependent care expenses.
A Flexible Spending Account (FSA) allows you to set aside pretax dollars from each paycheck to pay for certain IRS-approved health and dependent care expenses. We offer two types of FSAs: one for health care expenses and one for dependent care expenses. TASC administers our FSAs.
Health Care FSA
The Health Care FSA covers qualified medical, dental and vision expenses for you or your eligible dependents. Clark Community Mental Health will contribute $500 annually to your FSA account. You may contribute up to an additional $2,900 annually to a Health Care FSA and you are entitled to the full election from day one of your plan year. Eligible expenses include:
z Dental and vision expenses
z Medical deductibles and coinsurance
z Prescription copays
z Hearing aids and batteries
You may not contribute to a Health Care FSA if you contribute to a Health Savings Account (HSA).
Dependent Care FSA
The Dependent Care FSA helps pay for expenses associated with caring for elder or child dependents so you or your spouse can work or attend school full time. You can use the account to pay for day care or baby sitter expenses for your children under age 13 and qualifying older dependents, such as dependent parents. Reimbursement from your Dependent Care FSA is limited to the total amount deposited in your account at that time. To be eligible, you must be a single parent or you and your spouse must be employed outside the home, disabled, or a full-time student.
DEPENDENT CARE FSA GUIDELINES
z Overnight camps are not eligible for reimbursement (only day camps can be considered).
z If your child turns 13 midyear, you may only request reimbursement for the part of the year when the child is under age 13.
z You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care.
z The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.
LIFE AND AD&D INSURANCE
Life and Accidental Death and Dismemberment (AD&D) insurance through Principal 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).
Voluntary Life and AD&D
You may buy 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%).
Employee
Spouse
Child(ren)
• Increments of $10,000 up to $500,000 New Hire Guaranteed Issue
• Age 70 or under: $150,000.
• Age 70 or older: $10,000.
• Increments of $5,000 up to $100,000 not to exceed 50% of your election
New Hire Guaranteed Issue
• Age 70 or under: $50,000.
• Age 70 or older: $10,000.
• Options of $2,000, $4,000, $5,000, or $10,000
• Children under 14: $1,000
VOLUNTARY LIFE AND AD&D RATES
View rates in Employee Navigator.
During Open Enrollment, no Evidence of Insurability (EOI) is needed for eligible coverage increases unless you experience a Qualifying Life Event and wish to add or increase coverage. EOI may still be required. Employees can find the EOI form in Employee Navigator under their benefits enrollment section.
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) for you to purchase through Principal Note: EOI is not needed during OE.
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, non-work-related injury, or pregnancy. 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.
VOLUNTARY SHORT TERM DISABILITY
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.
VOLUNTARY SHORT TERM DISABILITY RATES
View rates in Employee Navigator.
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-related expenses. The plans are offered through Principal and are portable.
Accident Insurance
Benefits are paid directly to you for covered accidental injuries, regardless of any other coverage you may have and you can spend it any way you choose. Benefits are paid according to a fixed schedule that includes benefits for hospitalization, fractures and dislocations, emergency room visits, major diagnostic exams, physical therapy, and more. Please refer to the benefit summary for details of the benefits.
ACCIDENT INSURANCE
Percentage of benefit paid for dismemberment is dependent on type of loss.
SUPPLEMENTAL INSURANCE
Critical Illness
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.
CRITICAL ILLNESS
Benefit Amounts Available
• Employee
• Spouse
• Child
Full Coverage
Alzheimer’s disease, amyotrophic lateral sclerosis, benign brain tumor, coma, heart attack, invasive cancer, loss of hearing, sight or speech, major organ failure, multiple sclerosis, occupational infectious disease, paralysis, Parkinson’s disease, stroke, childhood conditions
Partial Coverage
Carcinoma in situ, coronary artery disease, infectious disease
Skin cancer
Health Screening Benefit
$5,000 or $30,000
$2,500 or $15,000 25% of employee benefit
100% of benefit amount
25% of benefit amount
$250
$50
Pre-existing Condition Limitation 6/12*
*You may qualify for a benefit if you haven’t been treated for this illness (including being seen by a doctor or taking medication) in the 6 months prior to your coverage effective date or you’ve had coverage for 12 consecutive months.
CRITICAL ILLNESS RATES
View rates in Employee Navigator
SUPPLEMENTAL INSURANCE
Hospital Indemnity
The Hospital Indemnity plan helps you with the high cost of medical care by paying you a set amount when you have an inpatient hospital stay. Unlike traditional insurance that pays a benefit to the hospital or doctor, this plan pays you directly based on the care or treatment that you receive. These costs may include meals and transportation, childcare, or time away from work due to a medical issue that requires hospitalization.
PRINCIPAL HOSPITAL INDEMNITY
Pay Period Rates
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:
Clark Community Mental Health Center Human Resources
PO Box 100
Pierce City, MO 65723 417-476-1000
LEGAL NOTICES
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 Clark Community Mental Health Center 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. Clark Community Mental Health Center has determined that the prescription drug coverage offered by the Clark Community Mental Health Center medical plan is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered Creditable Coverage.
Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare prescription drug plan, as long as you later enroll within specific time periods.
You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare. If you decide to wait to enroll in a Medicare prescription drug plan, you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15 through December 7 but as a general rule, if you delay your enrollment in Medicare Part D after first becoming eligible to enroll, you may have to pay a higher premium (a penalty).
You should compare your current coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have a copy, you can get one by contacting Clark Community Mental Health Center 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 Clark Community Mental Health Center 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.
LEGAL NOTICES
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 417-476-1000
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 800-772-1213. 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).
January 1, 2026
Clark Community Mental Health Center
Human Resources / Kristi Latham PO Box 100 Pierce City, MO 65723 417-476-1000
Notice of HIPAA Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes numerous requirements on employer health plans concerning the use and disclosure of individual health information. This information known as protected health information (PHI), includes virtually all individually identifiable health information held by a health plan – whether received in writing, in an electronic medium or as oral communication. This notice describes the privacy practices of the Employee Benefits Plan (referred to in this notice as the Plan), sponsored by Clark Community Mental Health Center, hereinafter referred to as the plan sponsor.
LEGAL NOTICES
The Plan is required by law to maintain the privacy of your health information and to provide you with this notice of the Plan’s legal duties and privacy practices with respect to your health information. It is important to note that these rules apply to the Plan, not the plan sponsor as an employer.
You have the right to inspect and copy protected health information which is maintained by and for the Plan for enrollment, payment, claims and case management. If you feel that protected health information about you is incorrect or incomplete, you may ask the Human Resources Department to amend the information. For a full copy of the Notice of Privacy Practices describing how protected health information about you may be used and disclosed and how you can get access to the information, contact the Human Resources Department.
Complaints: If you believe your privacy rights have been violated, you may complain to the Plan and to the Secretary of Health and Human Services. You will not be retaliated against for filing a complaint. To file a complaint, please contact the Privacy Officer.
Clark Community Mental Health Center Human Resources PO Box 100 Pierce City, MO 65723 417-476-1000
Conclusion
PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations.
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272)
LEGAL NOTICES
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 July 31, 2025. 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
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/welcome-iowamedicaid/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
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp
Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-6185488 (LaHIPP)
LEGAL NOTICES
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
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-program-hipp. 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/healthinsurance-premium-payment-hipp-program
Phone: 1-800-440-0493
LEGAL NOTICES
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
– 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 July 31, 2025, 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 Clark Community Mental Health Center group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the Clark Community Mental Health Center 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
Clark Community Mental Health Center Human Resources / Kristi Latham PO Box 100
Pierce City, MO 65723 417-476-1000
LEGAL NOTICES
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Outof-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than innetwork costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
• Emergency services – If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s innetwork cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
• Certain services at an in-network hospital or ambulatory surgical center – When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-ofnetwork. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, outof-network providers cannot balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protections from balance billing. You also are not required to get care outof-network. You can choose a provider or facility in your plan’s network.
LEGAL NOTICES
When balance billing is not allowed, you also have the following protections:
• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay outof-network providers and facilities directly.
• Your health plan generally must:
» Cover emergency services without requiring you to get approval for services in advance (prior authorization).
» Cover emergency services by out-of-network providers.
» Base what you owe the provider or facility (costsharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
» Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you have been wrongly billed, you may contact your insurance provider. Visit www.cms.gov/ nosurprises for more information about your rights under federal law.
This brochure highlights the main features of the Clark Community Mental Health Center 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. Clark Community Mental Health Center reserves the right to change or discontinue its employee benefits plans anytime.
