2016–2017 Employee

BENEFITS GUIDEAnnual Enrollment for plan year: 8/1/2016–7/31/2017

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BENEFITS FOR YOU AND YOUR FAMILYWelcome to the Pediatric Associates benefit guide for 2016–2017!We are excited to announce the continuation of our valuable benefits package offering for our employees and their families for the 2016–2017 benefit plan year! We hope that you will find the information contained within this guide helpful and refer to it to help you maximize the value of your benefits throughout the entire plan year.

WHO IS ELIGIBLE?When reading this guide, please be mindful of the following icons, designating which employee group is eligible for each benefit:

REMEMBER: Open Enrollment is the only opportunity to enroll in the benefits program for the 2016–2017 plan year. New Hires will have 60 days from the date of hire to enroll into all benefit programs through the ADP Payroll Portal. Once enrolled, your elections will apply to the entire plan year, except in the instance of a qualifying event.

WELCOME...

All regular full-time employees of Pediatric Associates who are scheduled to work a minimum of 30 hours per week are eligible for benefits, effective the first of the month following 60 days of employment unless stated otherwise. Management with a supervisory role are eligible to participate in the health plan on their date of hire; dental and vision plans the first of the month following date of hire.

If you are a part-time employee working 24-28 hours a week, you are eligible for designated benefits the first of the month following 60 days of employment, unless stated otherwise.

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Pediatric Associates employees who choose to enroll dependents in coverage will need to provide: • For Children up to age 26 - Certificate of Birth, Adoption, or Legal Guardianship• For Spouses - Certificate of Marriage or your most recent tax filing• For a child age 26 or older who is mentally or physically disabled - A

statement of disability verified by your medical provider• For a child age 26 or older who lives with you AND is unmarried AND has no

dependent children of his/her own - Proof of your child's residence via a copy of his/her driver's license or an official joint bill or bank account statement

• For a child age 26 or older who is a full-time or part-time student AND is unmarried AND has no dependent children of his/her own - Proof of your child's current student status via a copy of the most recent semester's enrollment

Please provide your required documents verifying dependent eligibility to the HR/Benefits Department or fax them to 954-965-7338.

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NEW MDLIVE: VITUAL CARE, ANYWHEREEffective June 1, 2016, Pediatric Associates is pleased to offer access to telemedicine services through MDLIVE.

What is telemedicine? If you have a minor illness like a sore throat, runny nose, or a rash then going to the emergency room can be expensive and urgent care may be unnecessary. Also, you may not be able to see your primary care physician right away. Telemedicine through MD Live provides you with virtual access to board certified doctors for minor health conditions 24/7/365 from your phone or computer.

How will it work? Once the benefit becomes available in June you simply:1. Activate your account through the MD Live website using your date of birth

and last 4 digits of your Social Security Number2. Select a doctor when you need to receive care3. Consult with a doctor over the phone or through video chat from your

computer, smart phone, or tablet.

How much will it cost to use MD Live? Nothing! For 2016, employees and their family members enrolled in a Pediatric Associates Cigna Health plan can use MD Live at no cost.

Employees who are not enrolled can still sign up for MD Live on their own by visiting MDLive.com. Signing up is free but a cost will apply if you see a doctor (generally about $49 per visit).

What can I use MD Live for? Doctors through MD Live can help treat minor medical conditions such as:• Allergies • Urinary problems / UTI• Cough • Respiratory Problems• Ear Problems • Sore throats• Flu • Minor Skin Irritations • Nausea / Vomiting • And more!

Can MD Live doctors write prescriptions? Yes! Doctors are able to prescribe medications when appropriate. Prescription drug copays will apply if you have a prescription filled.

MDLIVE

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NON-TOBACCO USER AND WELLNESS DISCOUNTSIn addition to earning access to the Deductible Reimbursement Fund (a value of up to $10,000 depending on your medical plan and enrollment tier), Pediatric Associates is excited to continue to offer the non-tobacco user and biometric screening discounts for our medical plans. Similar to last year, the biometric screening discount is no longer based on participation only, but is now based on meeting the BMI threshold. For 2016, that BMI target threshold is 32 or less OR demonstrating a 2 point improvement in BMI from your 2015 screening (even if your BMI is above 32).

• Non-tobacco users will receive a $20 per paycheck discount

• Biometric screening participants who meet the BMI thresholds will receive a $25 per paycheck discount

In order to qualify for the non-tobacco user discount, you will need to take a cotinine test, offered free of charge during Annual Enrollment.

To earn the wellness discount, complete your biometric screening at any Pediatric Associates location no later than July 31, 2016. If you meet the BMI target, you will automatically have the wellness discount applied to your 2016–2017 medical premiums. If you are a new hire, you must complete within 30 days of effective date of coverage and your participation alone qualifies you for the discount (you will not be subject to the BMI target until the next Open Enrollment, if hired before December 31st).

Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact the Human Resources Department and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

2016–2017 SAVINGS:

PAYCHECK DISCOUNTS (ALL TIERS) OAPIN MEDICAL PLAN

OAP MEDICAL PLAN ANNUAL SAVINGS

Non-Tobacco User Discount $20 $20 $480

BMI Target Discount $25 $25 $600

TOTAL 2016–2017 Discounts $45 $45 $1,080

HIGHLIGHTS...

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CIGNA MEDICALPediatric Associates offers 2 Cigna medical plans, both with the same Open Access Network of providers. The biggest difference in the plans is that the OAPIN plan only covers In-Network providers. You should check to make sure your doctors are In-Network and if they are, you will pay less in copays and premiums for the OAPIN plan. The In-Network Open Access Plan is available to all eligible full-time employees. There are no plan design changes for the 2016–2017 plan year.

Tier No Discounts

Non-Tobacco User Discount

Only

BMI Target Discount

Only

Non-Tobacco User & BMI

Target Discount

2016-2017 Increase

IN-NETWORK ONLY (OAPIN) PLANEmployee Only $93.50 $73.50 $68.50 $48.50 $1.00Employee + Child(ren) $181.50 $161.50 $156.50 $136.50 $2.73Employee + Spouse $415.00 $395.00 $390.00 $370.00 $6.83Family $570.00 $550.00 $545.00 $525.00 $11.24

MEDICAL CONTRIBUTIONS - Per Paycheck Costs

PLAN DESIGN IN-NETWORK ONLY (OAPIN) PLANIn-Network

MEDICALDeductible- Individual/Family $3,500/$7,000Out-of-Pocket Max- Individual/Family $5,350/$10,700Deductible Reimbursement Fund- Your Requirement

Individuals are responsible for the first $500/Families for $1,000

Deductible Reimbursement Fund- PA’s Commitment

Individuals: up to $5,000Families: up to $10,000

Coinsurance 70%PCP Copay $25CCN Specialist Copay/Non-CCN Specialist Copay $50/$65Preventive Care (copays/deductibles may apply) 100%ER Copay $325Urgent Care Copay $50

PRESCRIPTION DRUG - Separate Out-of-pocket maximum of $1,500 individual/$3,000 familyRetail • Generic • Preferred Brand • Non-Preferred Brand

$10$50$100

Mail Order • Generic • Preferred Brand • Non-Preferred Brand

$20$100$200

PA DEDUCTIBLE REIMBURSEMENT- see page 5 for more details.Deductible Reimbursement Fund Deductible You Must Satisfy OAPIN Plan Maximum

Reimbursement

Individuals $500 $5,000

Families $1,000 $10,000

MEDICAL INSURANCE PLAN

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CIGNA MEDICAL

Pediatric Associates also offers an Open Access Plan (with higher copays and premiums) through Cigna to all eligible full-time employees. There are no plan design changes for the 2016–2017 plan year.

Tier No Discounts

Non-Tobacco User Discount

Only

BMI Target Discount

Only

Non-Tobacco User &

BMI Target Discount

2016-2017 Increase

OPEN ACCESS (OAP) PLANEmployee Only $100.14 $80.14 $75.14 $55.14 $2.60

Employee + Child(ren) $195.34 $175.34 $170.34 $150.34 $7.09

Employee + Spouse $453.17 $433.17 $428.17 $408.17 $19.26

Family $622.42 $602.42 $597.42 $577.42 $27.24

MEDICAL CONTRIBUTIONS - Per Paycheck Costs

PLAN DESIGN OPEN ACCESS (OAP) PLAN

In-Network Out-of-Network

MEDICALDeductible- Individual/Family $2,000/$4,000 $4,000/$8,000Out-of-Pocket Max- Individual/Family $3,250/$6,500 $6,250/$12,500

Deductible Reimbursement Fund- Your RequirementIndividuals are responsible

for the first $500 / Families for $1,000

Deductible Reimbursement Fund- PA’s CommitmentIndividuals: up to $2,750Families: up to $5,500

Coinsurance 80% 60%PCP Copay $30 60% after deductibleCCN Specialist Copay / Non-CCN Specialist Copay $60/$90 60% after deductiblePreventive Care (copays/deductibles may apply) 100% 60%ER Copay $325Urgent Care Copay $50

PRESCRIPTION DRUGRetail • Generic • Preferred Brand • Non-Preferred Brand

$10$70

$140Mail Order • Generic • Preferred Brand • Non-Preferred Brand

$20$140$280

PA DEDUCTIBLE REIMBURSEMENT- see page 5 for more details.

Deductible Reimbursement Fund Deductible You Must Satisfy OAP Plan Maximum

Reimbursement

Individuals $500 $2,750

Families $1,000 $5,500

MEDICAL INSURANCE PLAN COMPARISON

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DEDUCTIBLE CREDIT PROGRAM• Pediatric Associates has established a fund to reimburse you and your

dependents for your out-of-pocket costs for medical care. Each member is eligible for this reimbursement with proof of eligible expenses.

• Pediatric Associates will reimburse in-network deductible expenses over $500 (or $1,000 for employees covering dependents). The medical deductible is for major services such as admissions to the hospital, MRI’s, CT scans, etc.

• The program does not apply to dental or vision expenses.

DEDUCTIBLE CREDIT PROCESS1. Fill out the Medical Deductible Credit Form located on the ADP Portal.

2. Attach a deductible credit statement. Visit mycigna.com to print your deductible/OOP maximum tracker statement.

3. Submit to the Benefits Department via fax at 954-965-7338 or via email at benefits@pediatricassociates.com.

Forms must be completed no later than October 31, 2016 for reimbursement for the previous plan year.

DEDUCTIBLE REIMBURSEMENT REQUIREMENTSIn order to receive the deductible reimbursement, you will need to complete a biometric screening and a health assessment.

1. Biometric ScreeningYou can take the biometric screening in one of our offices by our Clinical Managers or you can have it done by your own primary care physician using a form found on the ADP Portal.

2. Health Risk Assessment Through taking the online HRA, TriWellness will determine your wellness score and show you where to start improving your health. Sign onto www.triwellnessconnect.net and click on “Start Your HRA” on the homepage.

Screening and assessment must be completed within 30 days of the new plan year or of joining the medical plan.

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OPTION 1: CIGNA DPPO PLAN DESIGN

PLAN DESIGN CIGNA DPPOIn-Network Out-of-Network

Annual Maximum $1,500 $1,000

Deductible (Individual/Family)

$50/$150 $100/$300

Preventive and Diagnostic Care 100% no deductible 100% no deductible

Basic Services 80% after deductible 80% after deductible

Major Services 50% after deductible 10% after deductible

Orthodontia 50% after deductible 50% after deductible

Orthodontia Lifetime Maximum (Separate from Annual Maximum)

$1,500 $1,500

DPPO RATES - BASED ON 24 PAY PERIODS

Enrollment Tier DPPO 2016-2017

IncreaseEmployee Only $15.93 $0.00Employee + Child(ren) $34.07 $0.00Employee + Spouse $30.79 $0.00Family $49.70 $0.00

Pediatric Associates offers you a second dental option, a plan based on a contracted fee schedule provided by Cigna Dental. This plan features:

• No Deductibles• Coverage for Pre-existing Conditions• No Annual Maximum for Plan Dentist and Plan• Preventive services, including two exams and cleanings per year, X-rays, and two

fluoride treatments for children.

This dental plan offers benefits only to covered Dentists in the Cigna DHMO network. Please visit www.cigna.com and reference benefit schedule “KASV9” for a complete listing. Once a provider is selected, ID cards will be provided to new enrollees only.

Please carefully review the plan summary before making a final dental plan selection.

DHMO RATES - BASED ON 24 PAY PERIODS

Enrollment Tier DHMO 2016-2017

IncreaseEmployee Only $7.93 $0.31Employee + Child(ren) $17.94 $0.69Employee + Spouse $13.36 $0.52Family $23.56 $0.91

CIGNA DENTAL FT PT

OPTION 2: CIGNA DHMO PLAN

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CIGNA VISION

PLAN DESIGN CIGNAIn-Network Out-of-Network

Exam Copay $10 N/A

Materials Copay $20 N/A

ExamCovered in Full

After Copay$45 allowance

Single Vision LensesCovered in Full

After Copay$32 allowance

Bifocal LensesCovered in Full

After Copay$55 allowance

Trifocal LensesCovered in Full

After Copay$65 allowance

Lenticular LensesCovered in Full

After Copay$80 allowance

Frames (Retail Allowance) $100 allowance $55 allowance

Contact Lenses (Retail Allowance)- Elective

$100 allowance $87 allowance

Contact Lenses (Retail Allowance)- Therapeutic

Covered in Full After Copay

$210 allowance

Frequency of ServiceExam Copay Every 12 months

Lenses Every 12 months

Frames Every 24 months

VISION RATES - BASED ON 24 PAY PERIODS

Enrollment Tier Rate 2016-2017 Increase

Employee Only $2.91 $0.15

Employee + Child(ren) $5.86 $0.28

Employee + Spouse $5.81 $0.28

Family $9.24 $0.44

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EMPOWER 401(k) RETIREMENT PLAN FT PT

The Pediatric Associates 401(k) Plan provides you the opportunity to save money on a pre-tax basis to help you on your journey to and through retirement. To jump start your efforts, Pediatric Associates provides automatic enrollment in the 401(k) plan the first of the month following 90 days of employment. This benefit is provided to all full and part-time employees.

About the Plan• You are automatically enrolled at a

3% pre-tax contribution rate, invested in a default asset allocation model.

• The Company provides a match of $0.50 for every dollar contributed up to 3% of earnings for the non-highly compensated employees.

Accessing the PlanOur mobile-optimized participant website gives you the ability to access your account wherever and whenever you want. Use the website to:

• Adjust contributions and rebalance your portfolio

• Request a loan, model a new loan or obtain outstanding loan information (if applicable)

To access your account online, visit www.empower-retirement.com/participant and select REGISTER from the Login box.

If you know your PIN:• Choose I have a PIN.• Enter your Social Security number

and PIN and click CONTINUE.• Provide your contact information

and create a username and password. Click REGISTER.

If you do not know your PIN:• Choose I do not have a PIN.• Complete the requested personal

information and click CONTINUE.• Provide your contact information

and create a username and password. Click REGISTER.

You can also access your account by phone at 1-800-338-4015. Automated services are available 24 hours a day, 7 days a week. Participant Service Representatives are available weekdays between 8 a.m. – 8 p.m. CT.

Plan AdvisorsIf you have questions about choosing fund selections, you can contact the Plan Advisors at Dwyer and Associates at 888-657-3767 to assist in this process as well as provide education on the funds available for investment. Questions related to the company’s 401(k) plan should be directed to the Plan Administrator, Director of Human Resources.

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CIGNA BASIC LIFE & DISABILITY & VOLUNTARY TERM LIFECOMPANY PAID BENEFITSBasic Life and Accidental Death & Dismemberment Insurance – CignaYou are eligible for Basic Life and AD&D the first of the month following 90 days of employment. Pediatric Associates provides basic life and accidental death through Cigna in the following amounts:

• $20,000 for Management

• $10,000 for FT employees

Group Long Term Disability Insurance – CignaGroup Long Term Disability (LTD) Insurance provides 60% of your monthly salary to a maximum monthly benefit of $5,000 in the event that you suffer an extended disability due to illness or accident, and you have been out of work for 90 consecutive days.

VOLUNTARY TERM LIFE - CIGNAIn addition to your employer paid life and AD&D insurance, you have the opportunity to purchase additional life insurance protection for you and your family through Cigna on the first of the month following 90 days of employment.

• INITIAL ENROLLMENT: You may elect additional coverage for yourself in increments of $10,000 up to 5x your annual salary or $500,000, whichever is lower, and coverage for your spouse in increments of $10,000 up to 2.5x your annual salary or $250,000, whichever is lower (spouse election may not exceed 50% of employee election). Cigna guarantees elections up to $100,000 for yourself and $50,000 for your spouse. If you elect coverage in excess of the guarantee issue amount, you must submit Evidence of Insurability (EOI). You may also elect coverage for your child in increments of $2,500 up to $10,000 (coverage is limited to $250 for children age 0-6 months). All coverage for children is guaranteed.

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VOLUNTARY BENEFITS

BENEFIT PERIOD

Max amount of time to receive benefits after becoming disabled:• 3 months

ELIMINATION PERIOD

Amount of time that must pass between the first day of disability and the day benefits are paid to you:• Accident/Sickness: 7 days/7 days• Pre-Existing conditions: Conditions present up to 3 months prior to

the plan effective date will be excluded from benefit eligibility for the first 12 months of the policy.

BENEFIT AMOUNT

This is the monthly benefit payable to you:• 60% of your regular earnings, up to $2,000 per week.

CIGNA SHORT TERM DISABILITY – INCOME PROTECTION You are eligible for Short Term Disability the first of the month following 90 days of employment.

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NEW: VOLUNTARY BENEFITS ONE-STOP SHOP ENROLLMENT PORTALAvailable for enrollment this fall, Pediatric Associates will be partnering with AlliantCHOICE Plus to offer employees access to a one-stop voluntary benefit shopping portal, where you can easily pick and choose benefits customized to your personal needs. More information will be provided once the online shopping portal is available. The products and vendors available to you are:

LEGAL: Hyatt Legal

PET: Nationwide

(VPI)

PURCHASING: Purchasing Power

ACCIDENT: Aflac & Unum

AUTO & HOME:

Liberty Mutual, MetLife, Travelers

DISCOUNT PROGRAM:

BenPlace

ID THEFT PROTECTION:

LifeLock

CRTICAL ILLNESS:

Aflac & Unum

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This plan offers coverage for a skilled or custodial care in a nursing facility, assisted living facility, hospice, rehabilitation, Alzheimer’s or residential care facility (the benefit includes, but is not limited to: nursing care, therapist, homemaker service, any other services provided by/through a licensed Home Health Care Agency). You are eligible on the first of the month following 90 days of employment.

Plan options range from coverage of $1,000-$6,000 per month with duration options of 1 year of coverage to lifetime coverage.

Option to elect buy-up coverage for yourself and/or dependent coverage for a variety of family members, including spouses, parents, siblings, grandparents, and in-laws.

All new elections will be subject to Evidence of Insurability.

Rates are age-banded and, depending upon the plan you choose, begin at the affordable rate of $4.50 per month.

To enroll in buy-up coverage, please visit UNUM’s website at http://w3.unum.com/enroll/pedassoc002.

UNUM LONG TERM CARE

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ADP SELF-SERVICE ENROLLMENT ONLINE

HOW TO ENROLL IN ALL YOUR BENEFITSWe will continue to use the online enrollment system hosted by ADP. We hope that you continue to find this enrollment process faster and more convenient. All changes to your benefits must be completed during Open Enrollment, between July 1 and July 15, 2016 or within the first 60 days of your start date if you are a new hire.

Prior to completing your Open Enrollment you must confirm and update some personal and dependent information.

1. Log on to the ADP Payroll Portal.

2. Navigate to the Benefits Tab and select Review/Change Benefits.

3. A wizard-based Enrollment Tool begins the Enrollment process. You can check your progress while you make changes, or stop in the middle to return later, and the system will remember where you left off. The following three benefit enrollment options are available:

• Walk me through this process (recommended) • I know the changes I want to make • Review my benefits coverage

4. When you are finished making your changes, click View/Print Summary of Changes for a print out of your changes. You can log out of ADP Payroll Portal by clicking Logout on the top navigation bar.

If you have any questions using the ADP Payroll Portal, or if you’ve made an enrollment error, please contact your HR team.

Discover how Pediatric Associates in providing mobile access to key HR functions - and enjoying improved productivity and worker satisfaction along the way.

Visit www.adp.com/mobilesolutions for more information.

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ADDITIONAL BENEFITS FT PT

AT&T TICKETS AT WORK

SAM’S CLUBSPRINT

PTO CASH-OUT INCENTIVE POLICYThe first payroll in December of each year, you may opt to have any PTO balance over 60 hours paid to you as a cash bonus at 75% of its value. Maximum PTO cash out is 40 hours.

DISCOUNT PROGRAMSAs an employee of Pediatric Associates, you are eligible for discounts and benefits from a variety of vendors.

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Did you know that Pediatric Associates Life Assistance Program (LAP) offers FREE benefits to you and to any immediate family members?

YOUR FREE LIFE ASSISTANCE PROGRAM OFFERS:• Confidential guidance and resources for short-term issues, via phone and web

access, 24/7 :

• In-person help with short-term issues (up to three sessions per person, per issue, per year)

• A 25% discount on in-person consultations with network lawyers

To learn more about the Cigna Life Assistance Program, visit www.cignabehavioral.com/CGI or call 800-538-3543.

CIGNA LIFE ASSISTANCE PROGRAM FT

– Family Concerns – Child/Parenting – Developmental/Attention Issue – Marital/Partner – Any form of abuse – Physical Health – Stress/Anxiety – Sexual Disorders – Depression Concerns

– Alcohol Problems – Drug Problems – Suicidal /Homicidal – Grief and Loss issues – Eating Disorder Issues – Anger Management – Job/Career Issues – Workplace Aggression – Gambling

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LEGAL NOTICES

Women’s Health ActThe Women’s Health and Cancer Rights Act of 1998 requires that all health insurance plans that cover mastectomy also cover the following medical care:• Reconstruction of the breast on which the mastectomy was performed,• Surgery and reconstruction of the other breast to produce a symmetrical appearance,• Prostheses and treatment of physical complications at all stages of the mastectomy,

including lymphedemas, and Mastectomy bras and external prostheses limited to the lowest cost alternative available that meets the patient’s physical needs.

Medicaid and the Children’s Health Insurance Program (CHIP)If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed on the next page, you can 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, you can 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, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.

You may be eligible for assistance paying your employer health plan premiums. You should contact your State for further information on eligibility. Web: www.flmedicaidtplrecovery.com Phone: 1-877-357-3268

To see if any more States have added a premium assistance program since January 31, 2015, or for more information on special enrollment rights, you can contact either:

U.S. Department of LaborEmployee Benefits Security Administrationwww.dol.gov/ebsa1-866-444-EBSA (3272)

U.S. Department of Health and Human ServicesCenters for Medicare & Medicaid Serviceswww.cms.hhs.gov1-877-267-2323, Ext. 61565

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Newborns’ and Mothers’ Health Protection ActFederal law (Newborns’ and Mothers’ Health Protection Act of 1996) prohibits the plan from limiting a mother’s or newborn’s length of hospital stay to less than 48 hours for a normal delivery or 96 hours for a Cesarean delivery or from requiring the provider to obtain preauthorization for a stay of 48 or 96 hours, as appropriate. However, federal law generally does not prohibit the attending provider, after consultation with the mother, from discharging the mother or her newborn earlier than 48 hours for normal delivery or 96 hours for Cesarean delivery.

Notice of Special Enrollment Rights for Medical/Health Plan CoverageIf you decline enrollment in a your employer’s health plan for you or your dependents (including your spouse) because of other health insurance or group health plan coverage, you or your dependents may be able to enroll in your employer’s plan without waiting for the next open enrollment period if you:

• Lose other health insurance or group health plan coverage. You must request enrollment within 30 days after the loss of other coverage.

• Gain a new dependent as a result of marriage, birth, adoption, or placement for adoption. You must request [medical plan OR health plan] enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

• Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical plan enrollment within 60 days after the loss of such coverage.

If you request a change due to a special enrollment event within the specified timeframe, coverage will be effective the date of birth, adoption or placement for adoption. For all other events, coverage will be effective the first of the month following your request for enrollment. In addition, you may enroll in your employer’s medical plan if you become eligible for a state premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days after you gain eligibility for medical plan coverage. If you request this change, coverage will be effective the first of the month following your request for enrollment. Specific restrictions may apply, depending on federal and state law.

Note: If your dependent becomes eligible for a special enrollment rights, you may add the dependent to your current coverage or change to another medical plan OR health plan.

Health Insurance Portability and Accountability Act (HIPAA)Pediatric Associates, in accordance with HIPAA, protects your Protected Health Information (PHI). Pediatric Associates will only discuss your PHI with medical providers and third party administrators when necessary to administer the plan that provides your health and welfare benefits or as mandated by law. A copy of the Notice of Privacy Practices is available upon request in the Human Resources Department.

LEGAL NOTICES

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Michelle’s Law Notice — Extended dependent medical coverage during student medical leavesYour employer’s plan may extend medical coverage for dependent children if they lose eligibility for coverage because of a medically necessary leave of absence from school. Coverage may continue for up to a year, unless your child’s eligibility would end earlier for another reason.

Extended coverage is available if a child’s leave of absence from school — or change in school enrollment status (for example, switching from full-time to part-time status) — starts while the child has a serious illness or injury, is medically necessary and otherwise causes eligibility for student coverage under the plan to end. Written certification from the child’s physician stating that the child suffers from a serious illness or injury and the leave of absence is medically necessary may be required.

If your child will lose eligibility for coverage because of a medically necessary leave of absence from school and you want his or her coverage to be extended, contact the Human Resources Department as soon as the need for the leave is recognized. In addition, contact your child’s health plan to see if any state laws requiring extended coverage may apply to his or her benefits.

Continuation Required by Federal Law for You and Your DependentsThe Continuation Required by Federal Law does not apply to any benefits for loss of life, dismemberment or loss of income.

Federal law enables you or your dependent to continue health insurance if coverage would cease due to a reduction of your work hours or your termination of employment (other than for gross misconduct). Federal law also enables your dependents to continue health insurance if their coverage ceases due to your death, divorce or legal separation, or with respect to a dependent child, failure to continue to qualify as a dependent. Continuation must be elected in accordance with the rules of your employer’s group health plan(s) and is subject to federal law, regulations and interpretations.

DisclaimerThis brochure is only a summary of the healthcare and income protection benefits that are available to Pediatric Associates employees and their eligible dependents. Official plan documents, policies, and certificates of insurance contain the details, conditions, maximum benefit levels and restrictions on benefits. These documents govern your benefits program. If there is any conflict, the official documents prevail. These documents are available upon request through the Human Resources Department. Information provided in this brochure is not a guarantee of benefits.

Medicare Part DIf you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a federal law gives you more choices about your prescription drug coverage. A copy of the notice is available upon request in the Human Resources Department.

LEGAL NOTICES

2016 - 20178/1/2016 - 7/31/2017