YOU AT YOUR BEST

BENEFITS
2018
 WELCOME
OneMain

Table of Contents
Welcome 03 Flexible Spending Accounts (FSA) 22

Benefits at a Glance 04 Commuter Benefit Program 23

What’s New for 2018? 05 Income Protection 24

All About Enrollment 06 401(k) Savings Plan 26

Enrollment Checklist 09 Financial Wellness 27

Quick Tips: Online Tools 10 Additional Benefits 28

Quick Tips: Take Charge of Your Health 12 2018 Team Member Contributions 31

Medical Plan Options 14 Required Notices 33

Prescription Drug Coverage 18 Medicaid / CHIP Information 39

Vision Insurance 20 Definitions 41

Dental Insurance 21 Helpful Contact Information 43

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Welcome
At OneMain, we truly value our team members, and our appreciation is reflected in our comprehensive benefits program.
We strive to offer you and your family the support of a complete benefits package with choices to help match your
personal health and insurance needs. We have carefully selected these programs with your best interest in mind, while
striving to be a “Great Place to Work.” By selecting the right combination of benefits, you can maintain good health and
protect you and your family from unexpected costs.

We are committed to helping you and your family achieve the financial and medical protection you need for today, and
the security you’ll want for the future. The Benefits Program is a significant part of OneMain’s total rewards package and
represents our strong commitment to the health and welfare of our team members.

Our competitive Benefit Program is designed to promote healthier lifestyles for you and your family. We provide access
to tools, education and a variety of resources to help reduce the risk of disease and injury. Selecting the right plan is one
of the most important decisions you can make.

Elections you make during Open Enrollment are effective January 1, 2018 through December 21, 2018. This guide
will help you understand the benefit choices you can make before the enrollment deadline. Benefit information is also
located on MainStreet.

With you at your best, opportunities – both personal and professional – are endless.

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Benefits at a Glance
UnitedHealthcare
Express Scripts - Platinum Rx
Medical/Prescription Drugs OptumHealth – HSA
Kaiser Permanente (CA residents only)
HMSA (HI residents only)
ŸŸ Value Consumer Driven Health Plan (CDHP)
+ Health Savings Account (HSA)
ŸŸ Savings CDHP + HSA
ŸŸ PPO
ŸŸ HMO – Kaiser / HMSA

ŸŸ Preventive Plan
Dental MetLife
ŸŸ Enhanced Plan

Vision Vision Service Plan (VSP) ŸŸ VSP Choice Plan

ŸŸ Traditional Health Care FSA

Flexible Spending ŸŸ Traditional Dependent Day Care FSA
Your Spending Account (YSA)
Accounts (FSA) ŸŸ Limited FSA*
ŸŸ Commuter Benefit Program

ŸŸ Company Paid Team Member Life

ŸŸ Supplemental Team Member Life
ŸŸ Spouse Life
ŸŸ AD&D (for Team Member Only or Entire
Family)
Income Protection The Hartford
ŸŸ Dependent (Child) Life
ŸŸ Short-Term Disability
ŸŸ Long-Term Disability
ŸŸ Business Travel Accident

ŸŸ Critical Illness
ŸŸ Accident
Voluntary Benefits MetLife, ID Watchdog, Nationwide ŸŸ Identity Theft
ŸŸ Legal
ŸŸ Pet Insurance

*(CDHP members only)

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What’s New for 2018?
2018 CDHP Minimum Required Deductibles
To remain HSA eligible under IRS guidelines, the UHC Value Plan deductibles have increased:
• $1,350 for self-only coverage (up $50 from 2017)
• $2,700 for family coverage (up $100 from 2017)

Flex Spending, Commuter, and Health Savings Accounts Maximums

• Annual limit for both the Health Care and Limited Flexible Spending Accounts increased to $2,650.
• Commuter monthly pre-tax limit increased to $260.
• Health Savings contribution limit increased to $3,450 for individual and $6,900 for family.

Smart90 Walgreens
Team members enrolled in the United Healthcare medical plan with Express Script prescription coverage
may fill a 90-day mail-order maintenance medicine at the same co-pay/coinsurance as Express Scripts at
participating Walgreens

This Benefits Summary is intended only to highlight available benefits and should not be relied upon to fully determine
coverage. The benefit plan may not cover all health care expenses. More complete descriptions of benefits and the
terms under which they are provided are contained in the Certificate of Coverage that you will receive upon enrolling
in the Plan(s). If this Benefits Summary conflicts in any way with the policy issued by the employer, the Policy shall
prevail. Summary Plan Descriptions are available on MainStreet and in the Benefits System.

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All About Enrollment
Eligibility
Team members are eligible to enroll themselves along with their qualified dependents in the Medical,
Prescription Drug (Rx), Dental, Vision and Life plans offered. Qualified dependents include:
• Legal spouse
• Same and opposite-sex domestic partner
• Children up to age 26 (medical, Rx, life)
• Children up to the age of 30 (dental and vision coverage)
• Disabled children (no age limit for coverage)
Domestic partner and child(ren) coverage will be subject to after-tax deductions and imputed income in
accordance with the Federal Tax Code. Legal spouses will be eligible to receive benefits on a tax-free basis.
This calculated fringe benefit is known as imputed income. This fringe benefit will increase your taxable
income. Therefore, your federal, state, Social Security and Medicare taxes may increase. As a result, your net
pay will decrease. Your health insurance premium will continue to be deducted on a pre-tax basis.
Please Note: When enrolling dependents, verification of eligibility must be provided. If you add new
dependents to coverage during enrollment or as a new hire, you will receive an email notification at work
and mailing to your home address on file requesting documents to verify dependent eligibility. The notice will
contain detailed instructions on collecting documents such as birth certificates, marriage licenses and tax
records. Acceptable documentation is listed on page 7 in the “Qualified Life Events” section.
Once you receive the request notice, you will be notified of the deadline to send copies to the Dependent
Verification Center. Failure to submit requested proof to will make your dependent(s) ineligible for
coverage and they will be immediately removed from benefits on a go-forward basis. In addition, you
will need to upload, fax or mail required documents to:

Fax: 877-965-9555
Mail: Dependent Verification Center
P.O. Box 1401
Lincolnshire, IL 60069-1401

Questions can be directed to 800-804-8502. For more information regarding eligible dependents, please refer
to the Definitions section of this guide.

Important Information About Covering Your Dependents

• Eligible dependent children can be covered until the end of the plan year in which they turn 26
for Medical, Rx and Life, and the day before they turn 30 on the Dental and Vision plan(s) (except
HMSA Medical).
• If you and your spouse / domestic partner are both employed at the company, you may each be
enrolled as a team member or covered as a dependent of the other, but not both (excluding Life
and AD&D coverage).
• Only one parent may enroll a child as a dependent.
When Coverage Begins
New Hires: Coverage is effective on the first of the month following date of hire. The benefits center will send

QUICK TIP: Any changes to your elections made during the Open Enrollment period will be effective January 1, 2018. For
new hires, coverage and premium payments are effective on the first day of the month following date of hire. Depending on
when you enroll during your 31-day enrollment period, you may be subject to retro premiums.

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a notification when you are eligible to enroll. This may take up to 14-days. Benefit premiums begin on coverage
effective date, and depending on when you enroll during the 31-day enrollment period, you may be subject to retro
premiums.

Example: If your full-time date of hire is March 5, your benefit elections are effective April 1.

Health and Welfare premiums are paid per pay period. Team members pay full benefit premiums on their first
check. Benefit premiums are not prorated.

Example: Sally works 80 hours during the pay period of 02/26/2018 through 03/11/2018. Her first day at work is
02/26/18. Per plan policy, her coverage is effective the first of the month following hire. Based on this plan rule,
her coverage that she is electing begins 03/01/18. Since she had coverage during this pay period, she will be
charged the normal per pay period premium due as she was covered for that time period.

Current Team Members: If you are currently benefit-eligible, each year you have an opportunity to evaluate and
make changes to your benefit elections during Open Enrollment. Health and Welfare premiums are paid per pay
period. Team members pay full benefit premiums on their first check. Benefit premiums are not prorated.

When to Enroll
New Hires: Enrollment must be completed within the first 31 days of employment.
Current Team Members: All benefit-eligible team members have the opportunity to re-evaluate and make changes
to their benefit elections during the annual Open Enrollment, with changes effective January 1 of the following year.
Please keep in mind that these elections will be in effect through December 31. Mid-year changes are only allowed
if you experience an IRS Qualified Life Event.

Qualified Life Events

During the plan year (January 1 through December 31), a team member may experience one of the IRS Qualified
Life Events listed below. A team member may be able to make changes if the Qualified Life Event is consistent with
the change requested. Team members must notify the Benefit Service Center within 31 days of the event date and
provide acceptable documentation. Examples of IRS Qualified Life Events are:
• Birth, Adoption or Legal Guardianship of a Minor
• Gain of New Coverage
• Medicare Coverage
• Death
• Marriage, Legal Separation or Divorce
• Loss of Coverage

Changes can include adding or dropping dependents from coverage, switching from no coverage to coverage or
increasing pre-tax savings accounts. In the case of birth, adoption or placement for adoption, if you timely enroll
within 31 days of the event, coverage will take effect on the date you acquired the new dependent child. Qualifying
Life Event changes. Examples are: marriage, divorce, loss of coverage, etc. Coverage is effective on the first day
of the month following the date the event occurred unless the event occurred on the first of the month. Events that
occur on the 1st are effective the first of the month. For example: You were married on June 1st, but reported it on
June 15th. Your coverage is effective on June 1st and you may be responsible for retro premiums*.
*Retroactive premiums require you to pay for insurance coverage based off the coverage effective date. You may notice extra money deducted from your paycheck until all retroactive premiums
have been paid.

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Qualified events that occur (2nd - 31st) are effective the first day of the month following the event date. For
example: You were married on June 15th and reported the event on July 5th. Your coverage is effective on
July 1st and you may be responsible for retro premiums* depending on when you completed the change to
your coverage.

If you experience a Qualified Life Event, please contact HRConnect at 800-804-8502 within 31 days of the
event date to make coverage changes. The dependent eligibility process can begin if applicable. If you do not
make changes to your elections within the 31-day period, your next opportunity will be during the annual Open
Enrollment with changes effective January 1 of the following year.

Acceptable documentation of the Qualified Life Event must be provided to the Dependent Verification
Center. The deadline for providing the documentation will be included in the communication. You will be
notified via email at work and hard copy mail to your home address on file. Examples include:

• Spouse: Copy of marriage certificate or most recent tax return

• Biological Child (up to age 26): Copy of birth certificate/birth announcement or copy of prior year’s federal tax return
showing dependent claimed on taxes
• Stepchild (up to age 26): Copy of birth certificate and copy of marriage certificate showing your spouse as the
biological parent
• Adopted Child (up to age 26): Copy of papers showing placement of child in your home; or a copy of final adoption
papers
• Disabled Child: Copy of birth certificate or copy of prior year’s federal tax return showing dependent claimed on
taxes and proof of incapacity must be received within 120 days after the date on which the maximum age (26) is
attained. Subsequent evidence of disability or dependency may be required as often as reasonably necessary to verify
continued eligibility.
• Legal Guardian (up to age 26): Copy of court order proving legal guardianship

Preparing to Enroll
Please refer to the checklist on the following page to ensure that you have all of the information and
documentation that you need prior to enrollment. The company offers numerous tools and resources to help
you make your benefit elections. Be sure to log in to MainStreet to learn more about the benefit programs.

How to Enroll
New Hires: Enroll online during the first 31 days of full-time employment.

Should you miss the New Hire enrollment window during your first 31 days of full-time
employment, you will not have the opportunity to enroll until the next Annual Open Enrollment,
with new elections effective January 1 of the following year, unless you experience an IRS
Qualified Life Event.

Please Note: Evidence of Insurability is not required for supplemental Team Member, Spouse and
Dependent coverage up to guaranteed issue ($750,000 for team member, $100,000 for spouse, $20,000
dependent) or Disability Insurance within the New Hire Event.

Current Team Members: If you are currently benefit-eligible, you will have the opportunity to evaluate and
make changes to your benefit elections during the Annual Open Enrollment period.

Prior to making your elections, you can log in to MainStreet to learn more about the Benefit Programs.

Should you miss the Open Enrollment period, you will not have the opportunity to make changes until
the next Annual Open Enrollment. New elections are effective January 1 of the following year, unless you
experience an IRS Qualified Life Event.

QUICK TIP: Be sure to have the Social Security numbers and birth dates for any eligible dependents that
you plan to enroll. You will not be able to complete your enrollment without this information.

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Enrollment Checklist
Before Enrollment
FF Review the 2018 Benefits Guide.
FF Visit MainStreet for more information on the benefit programs.
FF Use the myHealthcare Cost Estimator tool to pick the best plan for you and your eligible dependents.
FF Share this information with your eligible dependents to ensure you elect the best plan(s) for your family.
FF Collect applicable paperwork needed to confirm dependent eligibility. (See page 7 of this guide.)
FF Consider contributing to your HSA. Calculate your annual goal amount.

FF If enrolling in the UHC Value or Savings CDHP with Health Savings Account (HSA) plan:
FF Decide if and how much you would like to contribute to an HSA. The employer contributions cannot begin
unless you agree to the HSA affidavit.
FF Consider contributing to a Flexible Spending Account (FSA) and use your pre-tax money on qualified expenses.
Calculate your annual goal amount.

During Enrollment
FF If enrolling in the UHC Value or Savings CDHP with HSA plan:
FF Make your HSA election.
FF Complete the OptumHealth Bank affidavit to establish your HSA and receive your Plan Sponsor’s
contribution. OneMain will contribute money per pay period to your HSA account. You do not have
to contribute money to receive this benefit. The affidavit agreement is available online during the
enrollment process.
FF Make your 2018 Traditional FSA election if you have chosen to do so (excluding UHC Value and Savings CDHP
members).
FF Make your 2018 Dependent Day Care FSA election if you have chosen to do so.
FF Make your 2018 Limited Purpose FSA election if you have chosen to do so. (Value and Savings CDHP members only).
The limited purpose FSA only covers dental and vision expenses.
FF Confirm if you are tobacco free. If not, a $50 monthly charge will automatically apply.
FF Designate or update your beneficiary(ies) (REQUIRED).
FF Click “Confirm Your Enrollment.” To ensure your elections are saved and submitted.
Please Note: Your elections will not be activated unless you “confirm” your elections.
FF Print, review and save your confirmation statement.

After Enrollment
FF On your first day of active coverage (or on January 1), log in to the benefits system and review your current
elections. Should you notice any errors, please notify HRConnect immediately at 800-804-8502.*
FF Review your benefit deductions on your first applicable paycheck (or your first paycheck in 2018). Should you notice
any errors, please notify HRConnect immediately at 800-804-8502*.
FF If you enrolled in any or all of the Supplemental Life Insurance plans and have submitted your EOI to The Hartford,
please note that you will be notified of The Hartford’s decision by mail to your home address on file. If approved, your
elections and premium will be updated in the next applicable pay period. Please be sure to check your paycheck to
view your new deduction(s).
Please Note: If you are unable to log in to the benefits system at any time, please contact HRConnect at 800-804-8502.
* Changes to your benefit elections after an enrollment period closes may or may not be honored.

QUICK TIP: Print this page and keep it with you for easy reference when you complete your enrollment.

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Quick Tips: Online Tools
If you participate in one of the UHC Medical Plans, you can take advantage of member discounts and utilize tools that
will assist you to choose the best of care through your secure member portal.

Understanding your benefits: Using network providers may help save you money
What You Need To Know: UHC has a large network of labs, physicians, medical groups, clinics and other health care
providers available for your use. These providers have agreed to charge UHC health plan members lower rates. To help
improve quality of care and save you from paying higher out-of-pocket costs, it is important that you use a network lab
or provider.

What You Can Do: When you log in to www.welcometouhc.com/onemain or download the UHC Health4MeTM app,
select “Find a Physician, Laboratory or Facility” or click on “Find a Doctor.” Once you are logged in, you’ll get 24/7
access to a personalized website that helps you manage your health plan and your health information. Easy-to-use tools
and resources make it simple to:

• Find network doctors and compare costs

• Locate a network doctor, virtual visit provider and mental health resources
• View preferred providers and see their reviews
• See what’s covered and get information about included preventive care
• Certain preventive services are covered without charging a deductible, copayment or coinsurance when
these services are provided by a network provider
• View claim details and account balances
• View your explanation of benefits (EOBs)
• See your claims and review costs and charges
• Track account balances for Health Savings Account (HSA)
• Print temporary ID card and order additional cards if needed.

The “myHealthcare Cost Estimator” Tool — Be a Good Consumer

Did you know that the decisions you make for your benefits can have an effect on your co-workers? UnitedHealthcare
(UHC) plan options are self-funded, which means actual costs of care are shared between plan participants and the
company. These premiums could increase in the future if we’re irresponsible about how we use our insurance, so it pays
for everyone to become educated health care consumers.

How Much Will My Plan Cost Me? Check out the myHealthcare Cost Estimator tool to project your 2018 medical
expenses. The Health Plan Cost Estimator tool helps you compare estimated health care expenses between the health
plans OneMain offers, so you can decide which health plan is most appropriate for you and your family. The information
you provide is private.

Use the Cost Estimator tool on myuhc.com/onemain or the Health4Me app to check on the cost of services and
providers before you make appointments.

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My Rx Choices – Immediate Access to a Pharmacist
Use My Rx Choices, the prescription savings program that lets you help your doctor save you money.
In addition to helping you save money, Express Scripts will check your chosen alternatives for
possible drug interactions.

Comparison shopping for possible lower-cost maintenance medications:

• Side-by-side drug comparisons showing plan pricing via retail and home delivery
pharmacies for brand name and generic-equivalent medications, if available
• Potential savings by drug and/or channel option
• Print for doctor review
• Medical history
• Go to Express-Scripts.com and select Register Now or download the Express Script App

Using the Express Scripts App to Manage Your Prescriptions

The Express Scripts mobile app helps you stay on track with taking your long-term medicines as
prescribed. (Long-term medicines are those used to treat conditions such as diabetes, high blood
pressure and high cholesterol)

Go to your smartphone’s app store, search for “Express Scripts” and download it for free today.

After downloading the app, log in with your online express-scripts.com user ID and password to
open. With the app you can:

• Quickly and easily manage your home delivery prescriptions – refill and renew them right
from your phone.
• Track your home delivery prescription orders right from your phone.
• Look up potential lower-cost prescription options available under your plan and discuss
them with your doctor – even while you’re still in the doctor’s office.
• Review your personalized alerts to help ensure that you are following your treatment plan
as prescribed by your doctor.
• View your medicines and set reminders for when to take them or to notify you when you
are running low. Get personalized alerts if there’s a possible health risk related to your
medicines. You can also add over-the-counter medicines, vitamins and supplements to
check for possible interactions with your prescriptions.
• Use your phone to display a virtual card that you can show at the pharmacy.

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Quick Tips: Take Charge of Your Health
Preventive Care — The First Step
Did you know that annual physicals (using an in-network doctor), immunizations, mammograms and many other
screenings are covered at 100% with no copay or deductible?* Studies show that getting regular preventive
care is one of the best things you can do to stay healthy. Use your preventive care now to help avoid more
complex or costly treatment down the road.

The Patient Protection and Affordable Care Act requires the company’s medical coverage to pay 100% for
certain services defined by the U.S. Department of Health & Human Services (HHS). The list does change
periodically, but visit the HHS website (hhs.gov/healthcare/facts/factsheets/2010/07/preventive-services-list.
html) for more details.

Health Assessment — Your Personal Health Checkup

Have you checked on your health lately? Regardless of whether or not you choose to participate in the
company’s medical coverage, you can complete a free online Health Assessment Questionnaire.

Upon completion, you will receive immediate, confidential results. You will learn what you’re doing right, where
you can improve and how to live healthy every day. Please note: The company will not have access to your
personal health information.
If you are enrolled in medical coverage, you have access to a phone line staffed with registered nurses 24 hours
a day, 7 days a week who can help you with general health questions; determining if an emergency room visit
is needed; finding a doctor or hospital; answering questions regarding prescriptions; helping you understand
treatment options; and providing tips on nutrition and health screenings.

UHC MyNurseLine: 877-440-0252

Kaiser Permanente 24-Hour Service Line: 800-464-4000

Live Tobacco Free! Save Your Health and Your Money

If you are tobacco free, you will pay lower team member contributions for the medical plan.

If you use tobacco and want to quit, you have the opportunity to participate in the UHC tobacco cessation
program, Quit for Life. Once the program is completed and you are tobacco free, you will be eligible for lower
team member contributions.

Not only will you become healthier when you quit, but if you successfully complete the program, you will be
eligible for a $50 per month discount on your UnitedHealthcare medical plan contributions for 2018. You will
receive the discount on medical plan contributions after you have successfully completed the program and your
program completion has been confirmed. Please note: This discount applies only to team members who are
tobacco free; it does not apply to covered dependents.

Ready to quit for good? Benefit eligible team members can call 866-784-8454 or visit quitnow.net. The $50 per
month discount is not applicable if you reside in Hawaii.

If it is unreasonably difficult due to a medical condition for you to achieve the standards for the reward under
this program, or if it is medically inadvisable for you to attempt to achieve the standards for the reward under
this program, call HRConnect at 800-804-8502 and we will work with you to develop another way to qualify for
the reward.

*Certain preventive health services will be covered based on age, gender and other factors without cost sharing (100% without charging a copayment, deductible or coinsurance), as long
as you receive these services from a network provider. Always refer to your plan documents for specific benefit coverage and limitations, or call the toll-free member number on your health
plan ID card.

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NovuHealth
We believe that healthy choices deserve to be rewarded, which is why we offer you an online wellness platform
called NovuHealth. With NovuHealth, the benefits of making positive changes extend beyond a healthier body
and a happier mind. Every action you take for better health earns you points. You can redeem those points for
raffle tickets, discounts at local businesses and charitable contributions. Keep your fitness fresh with programs
like Nutrition, Strength and Stress Management. There are daily health tips and weekly challenges to help you
avoid workout boredom. You can get and give support in the community of people working to get healthier, and
find advice from experts like dietitians and personal trainers. It’s your health. Take control and get rewarded.

All team members are eligible for this benefit and can access the wellness site by visiting the following link:
https://www.novu.com/join/onemain

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Medical Plan Options
UHC Value and Savings Consumer Driven Health Plan
(CDHP) + HSA Looking Ahead
The Value and Savings Consumer Driven Health Plans (CDHPs) offer a The Company Annual HSA Contribution:
lower deduction per paycheck; however, they also have a higher deductible $500 (team member only) and $1,000
that you must pay before your coverage begins. Pairing a Health Savings (team member + dependent) is distributed
Account (HSA) with the Value or Savings CDHP allows you to set aside per pay period to team members enrolled
pre-tax money to be used for qualified health care expenses. in the HSA.

Like the PPO plan, the Value or Savings CDHP + HSA plan uses the UHC
network of providers. If you or one of your enrolled dependents utilizes the
network, you will have lower out-of-pocket expenses. If seeking out-of-
network services, your cost may be higher and you will be responsible for
obtaining prior authorization by call UHC before services are provided.

How the Value or Savings CDHP + HSA Works 2018 Annual HSA Maximum
Contribution Limits (Set by the IRS)
Eligibility Requirements:
Deductible:
• Must be enrolled in the Value or Savings CDHP
• Individual: $1,350 (Value)
• Must not be enrolled in Medicare $1,800 (Savings)
• Must not be covered by other medical insurance(s) • Family: $2,700 (Value)
$3,600 (Savings)
• Must not have received VA medical benefits at any time
within the past three months
Save Year-Over-Year
• In addition to your own pretax contributions, the company
will make an employer contribution to your Health Savings
Account (HSA).
• Unused funds roll over, each year – there is no “use it or
lose it” rule. Contribution*:
• Individual: $3,450
• An HSA Debit Card is provided to all newly enrolled team
members and can be used to pay for qualified medical • Family: $6,900
expenses billed from an insurance company, a physician’s • 55+ Catch Up Contribution:
office or a pharmacy. $1,000
Please Note: OptumHealth Bank cannot create an account
with a P.O. Box

Higher Deductibles
• You are responsible for your medical and prescription
expenses until your Value or Savings CDHP deductible*
is met.
• Provided you enroll in an HSA, you may use pretax HSA Employer per pay period
monies to pay for eligible, out-of-pocket expenses. Contribution**:
Coinsurance • Team Member Only: $19.23
• After you meet the deductible, the company pays 90% of your • Team Member + Dependent:
eligible medical expenses under the Value CDHP and 80% $38.46
under the Savings CDHP. *Note: Employer contribution counts toward annual HSA
maximum limits.
• You are responsible for 10% coinsurance under the Value CDHP **Note: Team members must accept the HSA
affidavit to receive the employer contribution.
and 20% under the Savings CDHP. This can be paid with your
tax-free HSA, or you can choose to pay out of your pocket.
* In-Network Coverage. Your Platinum CDHP benefits includes a list of primary preventive medications that bypass the
Deductible and you pay the applicable copay/coinsurance until you have met the annual out-of-pocket maximum. This list
includes drugs that treat, for example, high blood pressure and high cholesterol.

14
 QUICK TIP

To set up your HSA and

receive the Plan Sponsor
employer contributions and
your HSA debit card, be
sure to agree to the affidavit
during enrollment.

Out-of-Pocket Maximum
• If you reach the annual out-of-pocket maximum, your Plan Sponsor will pay 100% of eligible
expenses for the rest of the year.
Additional Benefits
• You can change your HSA contribution at any time throughout the year, up to the IRS maximum.
• You have greater flexibility when it comes to how you spend money for health care expenses — you
can choose to either use the money in your HSA or pay out of pocket.
• The funds in the HSA are yours to keep — regardless of whether or not you stay in the UHC Value
or Savings CDHP from year to year.
Please Note: The HSA is not the same as a Flexible Spending Account (FSA). More information on an FSA can
be found on page 22 of this guide.

UnitedHealthcare (UHC) Preferred Provider Organization (PPO) Plan

The UHC PPO Plan allows you to enjoy the cost savings of an in-network benefit, while having the flexibility to
see non-network providers when you choose. Primary Care Physician designation or referrals are not needed
– you may freely move in and out of network accordingly. If seeking out-of-network services, your cost may be
higher and you will be responsible for obtaining prior authorization by call UHC before services are provided.
Eligible out-of-pocket costs (e.g., copays, deductibles, Rx copays, reasonable and customary charges) can be
reimbursed with your own pretax dollars through your Health Care Flexible Spending Account (FSA).

Kaiser Permanente HMO Plan (CA Residents Only)

For California residents, in addition to our UHC option, the company offers a Kaiser Permanente Health
Maintenance Organization (HMO). As a member of this HMO, you’re required to choose a Primary Care
Physician (PCP). Your PCP will take care of most of your health care needs; however, to see a specialist, you
need to obtain a referral before your appointment.
Eligible out-of-pocket costs (e.g., copays, Rx copays) can be reimbursed with your own pretax dollars through
your Health Care FSA.

Hawaii Medical Service (HMSA) HMO Plan (HI Residents Only)

For more information about plan coverage, log in to MainStreet or hmsa.com.

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Medical Plan Options
Comparing Your Medical Plan Options

UHC Savings CDHP UHC Value CDHP Kaiser HMO

UHC PPO Plan
with HSA with HSA (CA Only)

*Out-of- *Out-of- *Out-of-

In-Network In-Network In-Network In-Network
Network Network Network

Northern 603505 NCR

Group Number 730727
Southern 230920 SCR

Annual Deductible

Team Member Only $1,800 $2,800 $1,350 $2,500 $600 $1,500

N/A
Team Member + Dependents $3,600 $5,600 $2,700 $5,000 $1,200 $3,000

Annual Out-of-Pocket Maximum

Team member Only $5,000 $7,500 $4,000 $8,000 $3,000 $6,000 $1,500

Team member +
$10,000 $15,000 $8,000 $16,000 $6,000 $12,000 $3,000
Dependents

Coinsurance
(the percentage OneMain
80% 60% 90% 70% 80% 60% N/A
will pay after you meet your
deductible)

Primary Care and Deductible and Deductible and Deductible and

$15 / $30
Specialist Doctor Visits coinsurance coinsurance coinsurance

Deductible Deductible Deductible

& & &
Preventive Care 100% 100% 100% 100%
co- co- co-
insurance insurance insurance

Please refer to Please refer to Please refer to $10 / $20

Prescriptions prescription drug section prescription drug section prescription drug section $20 / $40
of this guide of this guide of this guide (mail order)

Please Note: Information on HMSA coverage plan can be found on MainStreet.

*If seeking out-of-network services, your cost may be higher and you will be responsible for obtaining prior authorization by calling UHC before services are provided.

16
Key Differences
Whether you choose the UHC PPO Plan or the UHC Value or Savings CDHP, you have a deductible to meet before plan
coverage begins. The way your expenses are counted toward your deductible differs, based upon whether you enroll in
the UHC PPO or one of the UHC CDHPs.

UHC PPO Plan UHC Value or Savings CDHP

Value CDHP: $1,350 (Individual) / $2,700 (Family)
Deductible* $600 (Individual) / $1,200 (Family)
Savings CDHP: $1,800 (Individual) / $3,600 (Family)

Prescription drug expenses No **Yes

count toward the deductible

Coinsurance for an individual 80%

Value CDHP: 90%
after you reach your deductible* Savings CDHP: 80%

Value CDHP: When the total eligible expenses for all

For example: If one member of the plan reaches
$600 of the $1,200 deductible, the plan will pay 80%
Coinsurance for family after coinsurance for that individual. Coinsurance will be
you reach your deductible* paid for the other covered persons once the family’s
expenses reach the out-of-pocket maximum.
members of the plan reach $2,700, the plan will begin
paying 90% of any in-network eligible expenses.
Savings CDHP: When the total eligible expenses for all
members of the plan reach $3,600, the plan will begin
paying 80% of any in-network eligible expenses.

Out-of-pocket maximum after Medical: $3,000 for Individual / $6,000 for Family Value CDHP: $4,000 (Individual) / $8,000 (Family)
your deductible* Rx: $2,000 for Individual / $4,000 for Family Savings CDHP: $5,000 (Individual) / $10,000 (Family)

*In-Network Coverage. **Your Platinum CDHP benefits includes a list of primary preventive medications that bypass the deductible and you pay the applicable copay/coinsurance until you have met the
annual out-of-pocket maximum. This list includes drugs that treat, for example, high blood pressure and high cholesterol.

QUICK TIP

Having trouble deciding?

Check out the myHealthcare
Cost Estimator tool to project
your 2018 medical expenses.

17
Prescription Drug Coverage
If you decide to enroll in one of the UHC health plans, you are enrolled automatically in the Express Scripts Platinum
Prescription Drug Plan. The plan covers both retail and mail-order prescriptions.

UHC Value, Savings or PPO Plan

Copay, Coinsurance, Minimums and Maximums

Retail (30-day Supply) Mail Order

Platinum Group Number AGF 1000

Generic $10 copay ($10 max) $25 copay ($25 max)

Formulary Brand 30% coinsurance ($35 min / $125 max) 30% coinsurance ($70 min / $250 max)

Non-Formulary Brand 50% coinsurance ($50 min / $150 max) 50% coinsurance ($100 min / $300 max)

30% coinsurance
($150 max. for 30-day supply,
Specialty N/A
$300 max. for 60-day supply,
$450 max. for 90-day supply)

Smart90 Walgreens
Greater flexibility for team members to fill 90 day mail-order maintenance medicines at Walgreens at the same
co-pay as Express Scripts.
Team members can still continue to use mail order at Express Scripts.

QUICK TIP: Taking advantage of mail order benefits can help you cut costs and avoid trips to the
pharmacy. For more information on this program, log in to:
UHC Members: express-scripts.com or call 877-508-4866
Kaiser HMO Members: kaiserpermanente.org

18
Important to Know
• Prescription drug costs do not apply toward the UHC PPO deductible, but they do apply to the
separate OOP maximum.
• Prescription drug costs do apply toward the UHC Value and Savings CDHPs + HSA deductible. However,
there is a list of primary preventive medications that bypass the deductible and you pay the applicable
copay/coinsurance until you have met the annual out-of-pocket maximum. This list includes drugs that
treat, for example, high blood pressure and high cholesterol.
• Step therapy is a program for people who take prescription drugs regularly to treat a medical condition,
such as arthritis, asthma or high blood pressure. It allows you and your family to receive the affordable
treatment you need.
• Step 1 medicines are generic drugs that have been rigorously tested and approved by the FDA. Generics
should be prescribed first because they can provide the same health benefits as higher-cost medicines.
• Step 2 medicines are brand-name drugs such as those you see advertised on TV. They’re recommended
only if a Step 1 medicine doesn’t work for you. Step 2 medicines almost always cost you and your plan
sponsor more than Step 1 medicines.
• Medicines requiring Prior Authorization - A prior authorization will be needed if you are currently taking a
medicine that is not on our formulary, and in some other situations.

Save Money and Be Safe With Express Scripts Prescription Drug Programs
Using the Express Scripts Pharmacy mail-order or Smart90 Walgreens program and purchasing generic
prescription drugs will save you money. Here are some of the ways to save on medications without
sacrificing quality of care:
Ask your doctor: “Is there a generic for that?”
Check it out during your checkup: Before leaving a doctor’s office with prescription in hand, be sure to ask
the doctor or nurse, “Is there a generic for that?”
• Give your prescriptions a checkup: Review all of your medications regularly with a doctor or pharmacist,
because there may be new, lower-cost treatments available.
• Find out before you fill: When you hand over a new prescription to your pharmacist, or during refill or
renewal time, ask, “Is there a generic for that?” The pharmacist can tell you and then call your doctor to
discuss changing the prescription accordingly.
• Understand the difference between equivalents and alternatives: A generic equivalent contains the same
active ingredients as the brand-name version; a generic alternative is similar to the brand-name medication
you currently use but is not the exact same medication. If there is no generic equivalent available, ask your
doctor or pharmacist if there is a generic alternative that would be clinically appropriate for you.

Comparison shop: The cost of medications can vary from pharmacy to pharmacy, so make sure to
comparison shop.

Ask for more: If you’re taking a medication for a chronic condition, ask your doctor to write a prescription
for a 90-day supply rather than one for 30 days because the cost will be lower for the higher quantity of
medication. Home delivery pharmacies provide 90-day supplies as do some retail pharmacies.

Splitting a high-dose pill: Depending on the specific drug you’ve been prescribed, pill-splitting can be
another option for reducing the cost of medications. If the price of a higher dose of the drug is similar to the
dose you’ve been prescribed, you should talk to your doctor or pharmacist about the safety of splitting the
pills. Some medications, such as time-release drugs and capsules, are not appropriate for pill-splitting.

Lifestyle changes: Simple lifestyle changes, such as diet and exercise, are often an effective way to
improve health outcomes.

Extended Payment Program: EPP allows you to spread your prescription payments over three credit or
debit card installments so you do not have to pay all at once.

19
 QUICK TIP

You don’t have to enroll in a

medical plan to have vision or
dental coverage. You can select
each plan individually.

Vision Insurance
Your Plan Sponsor offers vision coverage through Vision Service Plan (VSP) Group Number 30027751.

ID Cards are not issued. Policy / Member number is team member ID preceded by 00.

Benefit In-Network Out-of-Network

Visual Exam (every 12 months) $10 copay Up to $45

Primary Eyecare Visit (treatment and $10 copay N/A

diagnosis of eye conditions)

Prescription Lenses (every 12 months)

• Up to $30
Includes: Single Vision Lenses $10 copay • Up to $50
Lined Bifocal Lenses
Lined Trifocal Lenses • Up to $65

Progressives
$55
Includes: Standard Lenses $95-$105 • Up to $50
Premium Lenses
Custom Lenses $150-$175

Includes: Single Vision Lenses

Lined Bifocal Lenses $130 allowance for frames
Up to $70
Lined Trifocal Lenses 20% off any amount over $130

$130 allowance toward

Contact Lenses Up to $105
contact lenses and exam

20
Dental Insurance
Your Plan Sponsor provides two MetLife Dental Plan options for you to choose from:
• Enhanced Plan
• Preventive Plan
Please Note: All covered benefits are subject to reasonable and customary charges.

ID Cards are not issued. Policy / Member number is team member ID preceded by 00.

Enhanced PPO Preventive Plan

Group Number 147890
(% of Network PDP Fee) (% of Network PDP Fee)

Deductible
$50 individual / $150 family $50 individual / $150 family
Applies to Basic and Major Care Only

Preventive Care
100% 100%
Includes routine exams and cleanings

Basic Care
80% 70%
Includes fillings and simple extractions

Major Care
60% N/A
Includes bridges and dentures

Annual Maximum Benefit

$3,000 $1,000
(per person)

Orthodontic Care
Limited to separate $3,000 lifetime
maximum; dependent children to age 19 60% N/A
and adults covered under the Enhanced
Plan

QUICK TIP

Routine preventive care, such

as regular dental check-ups and
cleanings, can help lower your
risk of stroke and heart disease.
Learn more about what you can
do to improve your oral health at
the MetLife Oral Health Library.

21
Flexible Spending Accounts (FSA)
A Flexible Spending Account (FSA) is a pretax benefit allowable under Internal Revenue Code Section 125.
Your Plan Sponsor’s FSA plan allows you to set aside your own pretax dollars for unreimbursed health care
and dependent day care expenses. Participants can benefit by having fewer taxes deducted from their
paycheck as well as paying for eligible expenses with pretax dollars. You must re-enroll in the FSA accounts
every year.

There are three types of FSAs in our benefits program:

1. Traditional Health Care FSA

2. Limited FSA (only for those enrolled in the Value or Savings UHC CDHP) only covers dental,
vision and hearing diagnostic testing expenses
3. Dependent Day Care FSA

Your calendar year FSA amounts are deducted in equal installments from each paycheck. You must use the
balance by December 31, 2018.

Once you enroll in a Health Care FSA (Traditional or Limited), you will be given an FSA debit card. If you already
have a debit card and re-enroll in Health Care FSA, you can continue to use your same debit card. While the debit
card may always be used at qualified health care providers, it’s a good idea to save your receipts from your card
purchases in the event you are asked to substantiate a purchase. Substantiation for Tradition or Limited Health
Care FSA and Dependent Day Care reimbursements can be made online.

Please Note: If you do not use the balance in your account, you lose it. Balances do not roll over year over
year. Should your employment end, you have 90 days from your date of separation to submit expenses. You
can only submit expenses incurred up to your termination date, unless you have timely elected COBRA for
the FSA.

Traditional Health Care FSA (HC FSA)

This type of account can be set up for you and your eligible dependents whether or not you are enrolled in
medical, dental or vision plan(s). Examples of eligible expenses include: copays, deductibles, coinsurance,
glasses and contacts.

Dependent Day Care FSA (DC FSA)

This type of account is for the day care and protection of a dependent while you and your spouse are at work.
Dependents are defined as children under the age of 13 or a disabled spouse or parent who lives with you full
time whom you claim as a dependent on your taxes.

For child or elder care claims, your spouse must work at least part-time or be actively looking for work to be
eligible. Eligible expenses include accredited day care, day camp or visiting nurse services. (This account
cannot be used for medical, dental or vision expenses).

Limited FSA
Team members who are enrolled in the UHC Value or Savings CDHP are not eligible for a Traditional Health
Care FSA under current IRS regulations. Alternatively, UHC Value or Savings CDHP members are offered a
Limited FSA, which can be used for dental, vision and hearing diagnostic testing expenses only. Medical
out-of-pocket costs are ineligible.

2018 Contribution Limit

Health Care FSA Dependent Day Care FSA Limited FSA

Min $130/Max $2,650 Min $130/Max $5,000 Min $130/Max $2,650

22
Commuter Benefit Program
Select from the Transportation Spending or the Parking Spending Account. Use pretax money to save on
eligible commuter expenses (parking, bus, subway, train, etc.).

Visit www.irs.gov for 2018 monthly limits.

You may make elections on the benefit system or call 844-364-7657.

Please Note: You must enroll by the 10th of the month in order to participate in the following month. You can
elect or discontinue the commuter benefit at any time.

QUICK TIP

Do you already have an FSA debit

card from this year’s plan? Be sure
to keep your card. Even though your
balance does not roll over, you can
continue using the same card in 2018.

23
Income Protection
Life and Accidental Death & Dismemberment (AD&D)
The company automatically enrolls eligible team members in basic, group term life insurance equal to
one times your base salary at no cost (Basic Coverage). Your initial beneficiary designation must be made
during enrollment.

Please have your dependent’s information (i.e., Social Security number, date of birth and home address)
available at that time.

You may also choose to purchase Supplemental Life and AD&D insurance coverage for yourself and your
family (Supplemental Coverage). Spousal coverage cannot exceed 100% of the team member’s combined
Basic and Supplemental coverage. Team member may elect supplemental spouse life or dependent life
without electing supplemental team member life coverage.

If you are electing supplemental coverage, you may be required to complete Evidence of Insurability (EOI)
online during enrollment. Once completed and submitted to The Hartford, a medical exam may be required.
The Hartford’s decision is mailed to your home address on file. If approved, your elections and premium will
be updated for the next applicable pay period.

At annual enrollment, you may opt in or up by one level without evidence of insurability, up to the guaranteed
issue (applies to team member and spouse coverage).

• Dependent child age limit for life coverage is from live birth to age 26.
• Guaranteed issue levels: $750,000 for voluntary team member life; $100,000 for spouse life; and
$20,000 for dependent children.
• A team member who is married to another team member can be covered as both team member
and as a spouse under all life coverages. Spouse life maximum is the lesser of $250,000 or 100%
of team member’s combined basic and supplemental coverages.
• Age reductions apply (team member and spouse): 50% at age 70.
• When you experience a family status change, you may make changes to any supplemental life
coverage up to the guaranteed issue without evidence of insurability within 31 days.

The above is a summary only; refer to your The Hartford plan document for full coverage details.

Basic Coverage (Paid by Your Plan Sponsor)

ŸŸ 1x base salary
Basic Life ŸŸ Minimum: $50,000; Maximum: $250,000
ŸŸ Imputed income in excess of $50,000

Business Travel Accident ŸŸ Up to 5X base salary; Maximum: $3,000,000

Supplemental Coverage (Team Member Paid Post-Tax)

ŸŸ Up to 10X base salary; Maximum of $3,000,000
Team Member Supplemental Life ŸŸ Age reduction: 50% at age 70
ŸŸ Subject to EOI above GI

ŸŸ Increments of $10,000; Maximum: $250,000

ŸŸ Coverage cannot exceed 100% of team member’s combined
Spouse Supplemental Life Basic and Supplemental coverage
ŸŸ Age reduction: 50% at age 70
ŸŸ Subject to EOI above GI

ŸŸ Increments of $5,000; Maximum: $20,000

Dependent (Child) Supplemental Life ŸŸ No EOI required

ŸŸ Increments of $10,000
Accidental Death & Dismemberment (AD&D) ŸŸ Minimum: $20,000; Maximum: $3,000,000
ŸŸ No EOI required

24
 QUICK TIP

Should you need to use your disability

insurance, you are responsible for filing
the claim, notifying your supervisor and
the Leave Administration Unit. This can
be done by calling 866-958-4069 or
visiting thehartfordatwork.com. Save this
information to your phone or contacts list
for future reference.

Disability
In the event you become injured or suffer from an illness, eligible team members may be entitled to Short-Term
and Long-Term Disability compensation.

Short-Term Disability (STD) Coverage

OneMain provides eligible team members after 90 days of employment with Short-Term Disability coverage at no
cost. This benefit provides income replacement based on your years of service in the event you become disabled
due to your own serious medical condition. Benefits begin on the sixth day after you have been disabled for five
consecutive days, as defined by the policy. You may remain on STD up to 25 weeks in a rolling 12-month period.

Should you remain disabled past 25 weeks, you may be eligible for additional compensation under the
Long-Term Disability plan. Refer to the Time Away from Work policy located on MainStreet.

Long-Term Disability (LTD) Coverage

OneMain automatically enrolls eligible team members in LTD coverage at no cost. All covered team members are
eligible after 90 days of employment for this benefit once they have been disabled for 180 consecutive days.
• Basic LTD Coverage: 50% of total eligible compensation, up to a maximum of $5,000 per month.
• Team members are subject to a pre-existing conditions unless they have had the benefits for over
365 days.
Eligible team members have the opportunity to increase their LTD compensation benefit by an additional 10%, for
a total of 60% LTD coverage, up to a maximum of $30,000 per month.

Please Note: Evidence of Insurability (EOI) is required outside of the New Hire Qualified Status Event.

25
401(k) Savings Plan
Eligibility
Eligible team members may participate immediately on date of hire in the Company’s 401(k) plan through Transamerica
Retirement Solutions, and eligibility for company match begins 6 months following date of hire.

How to Enroll
Eligible team members can enroll online at work or at home. Go to trsretire.com/webportal/springleaf and select First-
Time Users, “New User? Get started now” or call 800-755-5801 to enroll.

Your Contributions
You can defer 1% to 50% of your pay in the 401(k) Plan. These contributions can be made on a pretax basis, an after-tax
basis (Roth 401(k)), or a combination of pretax and after-tax amounts, up to the IRS limits.

Company Match
The company offers a 401(k) Company match, dollar for dollar, up to a maximum of 4% of eligible earnings to all
contributing participants. You are 100% vested in the Company match after you meet the initial eligibility requirement.

Profit Sharing
The company may make a contribution to your 401(k) account when annual Company targets are met. Once you have
completed three years of service, you are 100% vested in the Profit Sharing contribution.

Rollovers
If you were a participant in another plan (for example, a qualified plan, governmental 457(b) plan or 403(b) account from a
previous employer), you may elect that a direct rollover or a participant rollover contribution be made into this plan from
the other plan.

Loans
You may take a personal loan for any reason for up to 5 years and can apply for a home loan for your principal residence
up to 15 years.

Withdrawals
You may withdraw all or a portion of your rollover contributions at any time, when you reach age 59 ½ or you experience
a hardship for an immediate and heavy financial need. Hardship withdrawals cannot exceed the exact amount to cover
financial need, plus any income taxes or penalties related to the hardship withdrawal.

Investing in the Plan

There are a variety of investment options offered by the plan to meet all participant retirement strategies.

26
Financial Wellness
OneMain offers a holistic approach to financial wellness by providing programs designed to help you take control of
your money, so you can focus on what matters – at work and in your life.

Tuition Reimbursement
OneMain’s Tuition Reimbursement Policy is designed to help team members further their knowledge, skills and job
effectiveness through higher education in fields of interest to the Company. OneMain provides reimbursement for
certain tuition expenses of up to $3,200 per calendar year.

• Team Member Eligibility – All active, regular full-time team members working 40 hours, listed as in Good
Standing, and have completed 90 days of service with the Company are eligible to apply.
• Required Approvals – Team members must submit a Tuition Reimbursement Application, which will
be routed to his/her manager for approval. Once the manager has reviewed and approved the Tuition
Reimbursement Application, the application will be routed to HR Administration for approval.
• Reimbursement Process – Obtain approvals as noted above. The team member should pay accredited
institutions directly. The Company will reimburse the team member for covered costs paid by the team
member once the course is completed.

Visit MainStreet for more information.

GuidanceResources® – Financial Connect:

The Financial Connect program Included in OneMain’s current ComPsych Team Member Assistance Program, offers
unlimited telephonic access to CFPs and CPAs to answer questions, including debt/money management, retirement
programs, budgeting, mortgages, loans and refinancing.

In-Depth Online Tools:

HelpSheets and interactive tools are available through GuidanceResources online, including understanding
Medicare, real estate and mortgage glossary, loan calculators, budget plans and articles.

Contact GuidanceResources any time for confidential support, information and resources:

• Call: 888-381-4327
• TOD: 800-697-0353
• Online: guidanceresources.com
• Company ID: VX3291S

Interactive Financial Webinars:

GuidanceResources periodically hosts interactive webinars for OneMain team members on relevant financial topics.

27
Additional Benefits
Voluntary Benefits Offering
49% of employees are truly concerned, anxious or fearful about their current financial well-being.1

We’re pleased to offer benefits designed to help you create a personal financial safety net that can help protect
you against the unexpected. Your medical and disability insurance may not be enough to cover all your extra
expenses and out-of-pocket costs associated with an accident or critical illness. Voluntary benefits are an easy
and cost-effective way to protect your income and savings while complementing your existing benefits.

Benefit details are outlined below. Refer to MetLife, ID Watchdog and Nationawide Pet Insurance coverage and
disclosure statements when enrolling for full benefit details.

Critical Illness Insurance

MetLife Critical Illness insurance provides a lump-sum payment if you or a covered family member is diagnosed
with one of the following medical conditions and meets the policy and certificate requirements: cancer, heart
attack, stroke, coronary artery bypass graft, kidney failure, Alzheimer’s disease, major organ transplant and 22
other listed conditions. Your plan pays a Recurrence Benefit equal to the Initial Benefit for the following covered
conditions: heart attack, stroke, coronary artery bypass graft, full benefit cancer and partial benefit cancer.
A Recurrence Benefit is only available if an Initial Benefit has been paid for the covered condition. There is a
Benefit Suspension Period between recurrences.
Payments are made directly to you, not to the doctors, hospitals or other health care providers. Checks are
mailed directly to your home. The payment you receive is yours to spend as you see fit.

Covered Condition Initial Benefit Recurrence Benefit

Full Benefit Cancer 100% of Initial Benefit 100% of Initial Benefit

Partial Benefit Cancer 25% of Initial Benefit 25% of Initial Benefit

Heart Attack 100% of Initial Benefit 100% of Initial Benefit

Stroke 100% of Initial Benefit 100% of Initial Benefit

Coronary Artery Bypass Graft 100% of Initial Benefit 100% of Initial Benefit

Kidney Failure 100% of Initial Benefit N/A

Alzheimer’s Disease 100% of Initial Benefit N/A

Major Organ Transplant Benefit 100% of Initial Benefit N/A

22 Listed Conditions 25% of Initial Benefit N/A

1
M e t L i f e ’s 1 5 th A n n u a l U .S . Em ployee Benefit Tr ends Study.
28
Group Accident Insurance
If you experience a covered event, accident insurance can help you be better prepared by providing you with a
payment to use as you see fit. There are no waiting periods for coverage to begin and payment is in addition to
any other insurance you may have. This payment can help you focus more on getting back on track and less on
the extra expenses an accident may bring.
This plan provides protection 24 hours a day – while on or off the job.
Examples of benefits included in this plan are shown below:

Medical Services & Treatment Benefit

Ambulance $300 - $1,000

Emergency Care $50 - $100

Non-Emergency Care $50

Physician Follow-Up $75

Admission $1,000 - $2,000 per accident

Confinement
(non-ICU confinement paid for up to 365 days; $200 (non-ICU) - $400 (ICU) a day
ICU confinement paid for 30 days)

Fractures $100 - $6,000

Accidental Death $50,000 / $25,000 / $10,000

ID Watchdog Identity Theft Insurance

Identity theft has become one of the fastest growing and most costly crimes in America today. Every 3
seconds, someone becomes the victim of identity theft. In 2013, approximately 13.1 million Americans
became victims of identity theft in 2013. ID Watchdog monitors billions of data points in both public and
private databases and alerts you of any new and updated information associated with your personal,
identifiable and financial information.

With a 24/7 Customer Care Center and fully managed resolution services, the identity resolution and
restoration process is fully managed by Certified Identity Theft Risk Management Specialists (CITRMS) who
serve as your dedicated case managers to provide you with a 100% guaranteed identity resolution.

When you enroll, you also receive:

• Reports that can identify any potential pre-existing conditions as far back as 30+ years
• Real-time credit alerts provided within minutes of detected activity change
• Assistance from our resolution experts will manage your case until it is completely restored
Additional features include social network alerts, sex offender notifications and a password manager.

29
MetLaw
MetLaw, the group legal plan available through Hyatt Legal Plans, makes things simple for you. You get the attorney
you need at a cost that’s very affordable, with access by telephone or in person for advice on an unlimited number of
personal legal matters, as well as representation for a wide variety of legal services. MetLaw could save you hundreds
of dollars in attorney fees for common legal services such as:

• Estate planning documents, including wills and trusts

• Real estate matters
• Identity theft defense
• Financial matters, such as debt-collection defense
• Traffic offenses
• Document review
• Family law, including adoption and name change
• Advice and consultation on personal legal matters
You’ll enjoy quick, easy access to a nationwide network of 13,000 prequalified Plan Attorneys with an average of 25
years of experience, offering a broad range of legal services. You can also choose a non-Plan Attorney and may be
reimbursed through the MetLaw plan. No matter how many times you use a Plan Attorney over the course of the year
for covered legal matters, all you pay is your monthly premium, no copayments and no deductibles.
The MetLaw premium is conveniently deducted from your paycheck, and there are no claim forms to fill out for network
service. Your spouse and dependent children also have access to the plan benefits for added peace of mind.

Nationwide Pet Insurance

Taking your pet to the veterinarian for one or more different reasons can be very costly. By having an insurance
policy in effect that covers your pet, you are able to minimize some of the medical costs associated with these visits
and treatments.
Nationwide provides benefits for veterinary treatments related to accidents and illnesses, including cancer. Medical
policies cover diagnostic tests, X-rays, prescriptions, surgeries, hospitalization and more. Competitively priced
wellness coverage can be added to any plan. Nationwide gives you access to the best care possible without straining
your budget.
• Use any veterinarian worldwide, including specialists and emergency providers
• Benefits that renew in full each year
• Nation’s oldest and largest pet insurer
• No additional charge for chronic care coverage
• No lifetime limits
Important: Pet insurance is not a payroll deduction, and it will not be deducted from your paycheck.

GuidanceResources® — To Help You With Life’s Challenges

Your benefits help you manage the everyday concerns of family life that can sometimes feel overwhelming. When life
presents challenges of any kind, online support and in-person counseling through GuidanceResources® are available
24 hours a day to provide expert and confidential support. These services provide help for a wide range of needs,
including legal support, child care, elder care, education, adoption, pet care and personal convenience. Contact
GuidanceResources® any time for confidential support, information and resources:

• Call: 888-381-4327
• TDD: 800-697-0353
• Online: guidanceresources.com
• Company ID: VX3291S

Business Travel Accident Coverage

You will automatically be enrolled in Business Travel Accident (BTA) coverage at no cost. This plan pays a
benefit if you suffer a covered loss as a result of an accident that occurs while traveling on Company business.

30
2018 Team Member Contributions
OneMain continues to pay the majority of the health care premium cost in 2018. However, as a health care
consumer, you should review your per pay period costs as well as the out-of-pocket health care costs you
estimate throughout the year. Team member contributions are listed below.

Savings CDHP, UHC Value and PPO Medical, Includes Platinum Rx

Savings CDHP UDH Value CDHP PPO
Savings CDHP UHC Value CDHP PPO
Per Pay Period (Not (Not (Not
(Tobacco-Free) (Tobacco-Free) (Tobacco-Free)
Tobacco-Free) Tobacco-Free) Tobacco-Free)

Team Member Only $41.83 $64.90 $54.12 $77.20 $94.63 $117.71

Team Member Only +

$96.38 $119.46 $121.31 $144.39 $211.42 $234.50
Spouse

Team Member +
$76.96 $100.03 $97.26 $120.33 $170.03 $193.11
Child(ren)

Family $137.80 $160.87 $173.28 $196.36 $302.00 $325.08

Kaiser HMO California Residents Only HMSA Hawaii

Kaiser California Kaiser California (Not HMSA Hawaii
(Tobacco-Free) Tobacco-Free)
Team Member Only $17.07
Team Member Only $73.46 $96.54
Team Member + 1 $112.44
Team Member + Spouse $146.92 $169.99

Team Member + Family $168.67

$132.22 $155.30
Child(ren)

Family $205.68 $228.76

QUICK TIP: You’ll save more on your per-paycheck cost if you are tobacco-free or successfully
complete a tobacco cessation program. Go to MainStreet to learn more about the Quit For Life program.

31
Dental Vision
Per Pay Period Rate Preventive Enhanced Per Pay Period Rate VSP

Team Member Only $7.65 $17.98 Team Member Only $3.06

Team Member + Spouse $15.67 $34.50 Team Member + Spouse $6.12

Team Member + Child(ren) $17.42 $38.93 Team Member + Child(ren) $6.55

Family $27.58 $61.22 Family $10.47

Team Member and Spouse Supplemental Life Insurance (After-Tax)

Team Member Only Spouse Only

Age Cost / $1,000 Age Cost / $1,000

34 & Under $0.022 34 & Under $0.022

35 to 39 $0.026 35 to 39 $0.026
40 to 44 $0.045 40 to 44 $0.045
45 to 49 $0.078 45 to 49 $0.078
50 to 54 $0.126 50 to 54 $0.126
55 to 59 $0.211 55 to 59 $0.211
60 to 64 $0.345 60 to 64 $0.345
65 to 69 $0.597 65 to 69 $0.597
*70 & Over $0.839 *70 & Over $0.839

Te a m m e mbe r an d S p o u se age r eductions apply: 50% at age 70

Dependent Supplemental Life (After-Tax) Voluntary AD&D (After-Tax)

Benefit Amount Cost Coverage Level Cost / $1,000

$5,000 $0.68 Team Member Only $0.012

$10,000 $1.35 Family $0.018

$15,000 $2.03

$20,000 $2.70

Voluntary Long-Term Disability (LTD) Buy-Up Coverage

You are covered automatically for a 50% LTD plan at no cost to you. You also have the option to buy up to a
60% LTD plan: $0.22 per $100 worth of coverage*.
* Subject to Evidence of Insurability and 365 day pre-existing condition limitations if not previously enrolled in company provided or Buy-up LTD.

32
Required Notices
Children’s Health Insurance Program Reauthorization Act of 2009 (CHIP)
Signed into law in order to expand state CHIP eligibility to more children and expectant mothers with an extended 60-
day time frame to coordinate any changes to employer health elections in the event of gain or loss of eligibility and / or a
subsidy under Medicaid or CHIP.

Continued Coverage Under COBRA

Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), you and your covered dependents may
be able to continue your health coverage if you lose your health care coverage as the result of certain qualifying events.
Contact the Human Resources Department for more information.

HIPAA Regulations Help to Protect Your Privacy

The privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) help to ensure that your
health care-related information stays private. New team members will receive a Privacy Practice Notice, which outlines the
ways in which the medical plan may use and disclose protected health information (PHI). The notice also describes your
rights. For more information, contact the Human Resources Department.

Mental Health Parity

Effective January 1, 2010, the Company-sponsored medical plans were modified to cover mental health and substance
abuse expenses subject to the same treatment limits, deductibles, copayments, coinsurance and out-of-pocket
requirements that apply to other medical and surgical expenses. This change applies to both inpatient and outpatient
services.

Newborns’ and Mothers’ Health Protection Act

Under federal law, health care plans may not restrict any hospital length of stay in connection with childbirth for the mother
or newborn child to less than 48 hours following a normal delivery, or less than 96 hours following a Cesarean section.
However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the
mother and with the mother’s consent, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable).

Notice of Availability of Reasonable Alternative Standard

Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program
are available to all team members. 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 Recourses
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 or you in light of your health status.

Notice of HIPAA Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or
group health plan coverage, you may be able to 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 request enrollment within 30 days after your or your dependents’ other coverage ends (or
after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be
able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth,
adoption or placement for adoption. To request special enrollment or obtain more information, please contact Benefits
Service Center at 800-804-8502.

Uniformed Services Employment and Reemployment Rights Act (USERRA)

USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake
military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from
discriminating against past and present members of the uniformed services and applicants to the uniformed services. The
act also states that if a team member leaves their job to perform military service, they have the right to elect to continue
existing employer-based health plan coverage for the team member and their eligible dependents for up to 24 months

33
Required Notices
while in the military. Even if the team member doesn’t elect to continue coverage during their military service,
they have the right to be reinstated in their employer’s health plan when they are re-employed, generally
without any waiting periods or exclusions (e.g., pre-existing condition exclusions), except for service-
connected illnesses or injuries.

Women’s Health and Cancer Rights Act of 1998

Under the Women’s Health and Cancer Rights Act, group health plans must make certain benefits available to
participants of health plans who have undergone a mastectomy. In particular, a plan must offer mastectomy patients
benefits for:
• Reconstruction of the breast on which the mastectomy was performed
• Any necessary surgery and reconstruction of the other breast to produce a symmetrical
appearance
• Prostheses
• Treatment of physical conditions related to the mastectomy, including lymphedema
Our medical plans comply with these requirements. Benefits for these items are similar to those provided under the plan
for similar types of medical services and supplies.

Your Rights Under Michelle’s Law

Effective January 1, 2010, full-time students covered under the group health plan that would otherwise lose eligibility under
the plan because of a reduction in their full-time class status due to a medically necessary leave of absence from school,
may be eligible to extend their coverage under the plan for up to one year, or to age 26, whichever occurs first. The child
must be a dependent child of a plan participant and be enrolled in the company group health plan on the basis of being a
student at a postsecondary educational institution immediately before the first day of the leave.

Patient Protection Disclosure – Selecting Your Primary Care Provider

Kaiser Permanente HMO and Hawaii Medical Service (HMSA) generally require the designation of a primary care provider.
You have the right to designate any primary care provider who participates in our network and who is available to accept
you or your family members. For children, you may designate a pediatrician as the primary care provider. You do not need
prior authorization from Kaiser Permanente HMO and Hawaii Medical Service (HMSA) or from any other person (including
a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional
in the network who specializes in obstetrics or gynecology. The health care professional, however, may be required to
comply with certain procedures, including obtaining prior authorization for certain services, following a preapproved
treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in
obstetrics or gynecology, contact the Kaiser Permanente HMO and Hawaii Medical Service (HMSA) at the numbers and
website in this guide.

AFFORDABLE CARE ACT (ACA)

The Patient Protection and Affordable Care Act, commonly called the Affordable Care Act (ACA), is a
United States federal statute signed into law by President Barack Obama in March 2010. The ACA includes
subsidies, health insurance exchanges and mandates, including an individual mandate that, with certain
exceptions, requires all individuals beginning January 1, 2014 to have health insurance or pay a penalty. The
law includes subsidies to help individuals with low incomes comply with the mandate. Coverage through the
health insurance exchange is guaranteed; even if you have a pre-existing medical condition, your cost for
coverage will be the same as all other applicants of the same age living in the same geographic location.

The health insurance exchange, sometimes called the Exchange or Marketplace, is a resource where
individuals can learn about private health coverage options, compare private health insurance plans, and
enroll in private health insurance coverage. The health insurance exchange also provides information
on programs that help individuals with low to moderate incomes and resources to pay for private health
insurance coverage.

You can get help online at www.healthcare.gov, or call 1-800-318-2596, 24 hours a day, 7 days a week.

34
FLSA
 / Exchange Notice


New Health Insurance Marketplace Coverage
Form Approved
Options and Your Health Coverage OMB No. 1210-0149
H[SLUHV5312020

PART A: General Information

ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ:͑ΥΙΖ͑͹ΖΒΝΥΙ͑
ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑
ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟
͑
What is the Health Insurance Marketplace?
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑
;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑
ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟΀ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑
ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑΀ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡

Can I Save Money on my Health Insurance Premiums in the Marketplace?

ΊΠΦ͑ΞΒΪ͑΢ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑
ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑
ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑
ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟͹ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑
ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑
ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑
ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑
ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑
ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑͟͢
͑
ͿΠΥΖͫ͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑
ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑
ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑
ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞
ΥΒΩ͑ΓΒΤΚΤ͑͟
͑
How Can I Get More Information?
ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑
OneMain Human Resources Department, 601 NW 2nd St, Evansville, IN 47708, 800.804.8502
ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟
͑
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑
;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟΁ΝΖΒΤΖ͑ΧΚΤΚΥ͑͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑
ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑͹ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟

͑͢ͲΟ͑ ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͑ ͓ΞΚΟΚΞΦΞ͑ ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ ΚΗ͑ ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑

ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ ΤΦΔΙ͑ΔΠΤΥΤ͑͟

35
FLSA / Exchange Notice
PART B: Information About Health Coverage Offered by Your Employer
΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑
ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑
ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟

3. Employer name 4. Employer Identification Number (EIN)

OneMain General Services Corporation 46-1095755
5. Employer address 6. Employer phone number
601 NW 2nd St 800.804.8502
7. City 8. State 9. ZIP code
Evansville IN 47708
10. Who can we contact about employee health coverage at this job?
OneMain Human Resources Department
11. Phone number (if different from above) 12. Email address
͑ HRConnect@OneMainFinancial.com
͹ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑
x ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑
… ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑
͑
Regular full-time employees who are scheduled to work at least 30 hours per week
͑
͑
͑
͑
… ΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑
͑
͑
͑
͑
͑
x ΈΚΥΙ͑ΣΖΤΡΖΔΥ͑ΥΠ͑ΕΖΡΖΟΕΖΟΥΤͫ͑
… ΈΖ͑ΕΠ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ͶΝΚΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟΥΤ͑ΒΣΖͫ͑
͑
Eligible spouses, civil union partners, and domestic partners
͑
͑
͑
… ΈΖ͑ΕΠ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟
͑
… ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑
ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟
͑
͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑
ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝
ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑
ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑
ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑΢ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟
͑
ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟͹ΖΣΖ͘Τ͑ΥΙΖ͑
ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑
ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟
͑

36
 FLSA / Exchange Notice
΅ΙΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΓΖΝΠΨ͑ΔΠΣΣΖΤΡΠΟΕΤ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ͶΞΡΝΠΪΖΣ͑ʹΠΧΖΣΒΘΖ͑΅ΠΠΝ͑͑͟ʹΠΞΡΝΖΥΚΟΘ͑ΥΙΚΤ͑ΤΖΔΥΚΠΟ͑ΚΤ͑ΠΡΥΚΠΟΒΝ͑ΗΠΣ͑
ΖΞΡΝΠΪΖΣΤ͑͝ΓΦΥ͑ΨΚΝΝ͑ΙΖΝΡ͑ΖΟΤΦΣΖ͑ΖΞΡΝΠΪΖΖΤ͑ΦΟΕΖΣΤΥΒΟΕ͑ΥΙΖΚΣ͑ΔΠΧΖΣΒΘΖ͑ΔΙΠΚΔΖΤ͑͟
͑
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in
the next 3 months?

… Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the
employee eligible for coverage? (mm/dd/yyyy) (Continue)
… No (STOP and return this form to employee)
͑

14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15) No (STOP and return form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include
family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she
received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on
wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

ͺΗ͑ΥΙΖ͑ΡΝΒΟ͑ΪΖΒΣ͑ΨΚΝΝ͑ΖΟΕ͑ΤΠΠΟ͑ΒΟΕ͑ΪΠΦ͑ΜΟΠΨ͑ΥΙΒΥ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΡΝΒΟΤ͑ΠΗΗΖΣΖΕ͑ΨΚΝΝ͑ΔΙΒΟΘΖ͑͝ΘΠ͑ΥΠ͑΢ΦΖΤΥΚΠΟ͑ͧ͑͢͟ͺΗ͑ΪΠΦ͑ΕΠΟ͘Υ͑
ΜΟΠΨ͑͝΄΅΀΁͑ΒΟΕ͑ΣΖΥΦΣΟ͑ΗΠΣΞ͑ΥΠ͑ΖΞΡΝΠΪΖΖ͑͟
͑
16. What change will the employer make for the new plan year?
… Employer won't offer health coverage
… Employer will start offering health coverage to employees or change the premium for the lowest-cost plan
available only to the employee that meets the minimum value standard.* (Premium should reflect the
discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

• An employer-sponsored 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
(Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

‫Ͳ͑ח‬Ο͑ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ΚΗ͑ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ΓΪ͑
ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ΟΠ͑ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ΤΦΔΙ͑ΔΠΤΥΤ͙͑΄ΖΔΥΚΠΟ͑ͤͧͳ͙Δ͚͙͚͙ͣʹ͚͙ΚΚ͚͑ΠΗ͑ΥΙΖ͑ͺΟΥΖΣΟΒΝ͑΃ΖΧΖΟΦΖ͑ʹΠΕΖ͑ΠΗ͚͑ͪͩͧ͑͢

37
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, 2017. Contact your state for more
information on eligibility.

38
Medicaid / CHIP Information
State Plan Phone / Website

myalhipp.com
Alabama Medicaid
Phone: 855-692-5447

health.hss.state.ak.us/dpa/programs/medicaid/
Alaska Medicaid Phone (Outside of Anchorage): 888-318-8890
Phone (Anchorage): 907-269-6529

colorado.gov/hcpf
Colorado Medicaid
Medicaid Customer Contact Center: 800-221-3943

flmedicaidtplrecovery.com/
Florida Medicaid
Phone: 877-357-3268

dch.georgia.gov/
• Click on Programs, then Medicaid, then
Georgia Medicaid
Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507

in.gov/fssa
Indiana Medicaid
Phone: 800-889-9949

dhs.state.ia.us/hipp/
Iowa Medicaid
Phone: 888-346-9562

kdheks.gov/hcf/
Kansas Medicaid
Phone: 800-792-4884

chfs.ky.gov/dms/default.htm
Kentucky Medicaid
Phone: 800-635-2570

dhh.louisiana.gov/index.cfm/subhome/1/n/331
Louisiana Medicaid
Phone: 888-695-2447

maine.gov/dhhs/ofi/public-assistance/index.html
Maine Medicaid Phone: 800-977-6740
TTY 800-977-6741

mass.gov/MassHealth
Massachusetts Medicaid / CHIP
Phone: 800-462-1120

dhs.state.mn.us/id_006254
Minnesota Medicaid • Click on Health Care, then Medical Assistance
Phone: 800-657-3739

dss.mo.gov/mhd/participants/pages/hipp.htm
Missouri Medicaid
Phone: 573-751-2005

medicaid.mt.gov/member
Montana Medicaid
Phone: 800-694-3084

ACCESSNebraska.ne.gov
Nebraska Medicaid
Phone: 855-632-7633

dwss.nv.gov/
Nevada Medicaid
Medicaid Phone: 800-992-0900

dhhs.nh.gov/oii/documents/hippapp.pdf
New Hampshire Medicaid
Phone: 603-271-5218

39
Medicaid / CHIP Information
State Plan Phone / Website

Medicaid Website: state.nj.us/humanservices/

dmahs/clients/medicaid/
New Jersey Medicaid / CHIP Medicaid Phone: 609-631-2392
CHIP Website: njfamilycare.org/index.html
CHIP Phone: 800-701-0710

nyhealth.gov/health_care/medicaid/
New York Medicaid
Phone: 800-541-2831

ncdhhs.gov/dma
North Carolina Medicaid
Phone: 919-855-4100

nd.gov/dhs/services/medicalserv/medicaid/
North Dakota Medicaid
Phone: 800-755-2604

insureoklahoma.org
Oklahoma Medicaid / CHIP
Phone: 888-365-3742

oregonhealthykids.gov
Oregon Medicaid hijossaludablesoregon.gov
Phone: 800-699-9075

dhs.state.pa.us/hipp
Pennsylvania Medicaid
Phone: 800-692-7462

eohhs.ri.gov/
Rhode Island Medicaid
Phone: 401-462-5300

scdhhs.gov
South Carolina Medicaid
Phone: 888-549-0820

dss.sd.gov
South Dakota Medicaid
Phone: 888-828-0059

gethipptexas.com/
Texas Medicaid
Phone: 800-440-0493

Medicaid: health.utah.gov/medicaid
Utah Medicaid / CHIP CHIP: health.utah.gov/chip
Phone: 866-435-7414

greenmountaincare.org/
Vermont Medicaid
Phone: 800-250-8427

Medicaid Website: coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 800-432-5924
Virginia Medicaid / CHIP
CHIP Website: coverva.org/programs_premium_assistance.cfm
CHIP Phone: 855-242-8282

hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx
Washington Medicaid
Phone: 800-562-3022 ext. 15473

dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx
West Virginia Medicaid
Phone: 877-598-5820, HMS Third Party Liability

dhs.wisconsin.gov/badgercareplus/p-10095.htm
Wisconsin Medicaid / CHIP
Phone: 800-362-3002

wyequalitycare.acs-inc.com/
Wyoming Medicaid
Phone: 307-777-7531

To see if any other states have added a premium assistance program since January 31, 2016, or for more information on special enrollment rights, contact
either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/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 or OMB Control Number
1210-0137 (expires 10/31/2018).

40
Definitions
Affordable Care Act (ACA): The Patient Protection and
Affordable Care Act, commonly called the Affordable
Care Act (ACA) is a United States federal statute
signed into law by President Barack Obama in March
2010. The law puts in place comprehensive health
insurance reforms.
Annual Maximum: Total dollar amount a plan pays
during a calendar year toward the covered expenses
of each person enrolled.
Brand Formulary Drugs: The brand formulary is
an approved, recommended list of brand name
medications. Drugs on this list are available to you
at a lower cost than drugs that do not appear on this
preferred list.
Child(ren) (as eligible dependents): You or your spouse’s
or eligible domestic partner’s child who resides
within the U.S. and is under age 26 (regardless of
student status, marital status, residence or financial
dependence). Children will be covered on the medical,
Rx and life plans until the end of the year in which
they turn 26 (or day before their 30th birthday for
dental and vision). Such children include:
• A natural child
• A stepchild
• A legally adopted child
• Child placed for adoption
• Child for whom you or your spouse or
domestic partner is the legal guardian
• Unmarried child age 26 or older who is or
becomes permanently disabled
• A child for whom health care coverage
is required through a Qualified Medical
Child Support Order (QMCSO) or other
court or administrative order
Coinsurance: A percentage of the medical costs, based
on the allowed amount, you must pay for certain
services after you meet your annual deductible.
Conversion: A team member changes or “converts”
her / his Group Life coverage to an Individual Life
Insurance policy without having to answer any
medical questions. Conversion is for a team member
who is leaving her / his job, reducing hours or has
reached the age when coverage may be reduced or
eliminated and still wants to maintain the protection
that life insurance provides.
41
Copayment: A set dollar amount you pay for network
doctors’ office visits, emergency room services and
prescription drugs.
Deductible: Total dollar amount, based on the allowed
amount, you must pay out of pocket for covered
medical expenses each calendar year before the plan
pays for most services. The deductible does not apply
to network preventative care and any services where
you pay a co-payment rather than coinsurance. Some
of your dental options also have an annual deductible,
generally for basic and major dental care services.
Generic Drugs: These drugs are usually most cost
effective. Generic drugs are chemically identical to
their brand name counterparts. Purchasing generic
drugs allows you to pay a lower out-of-pocket cost
than if you purchase formulary or nonformulary brand
name drugs.
Maintenance Drugs: Prescriptions commonly used to
treat conditions that are considered chronic or long
term. These conditions usually require regular, daily
use of medicines. Examples of maintenance drugs
are those used to treat high blood pressure, heart
disease, asthma and diabetes.
Medical Necessity or Medically Necessary: Health care
services or supplies needed to prevent, evaluate,
diagnose or treat an illness, injury, condition,
disease or its symptoms, that are all of the following
as determined by:
UnitedHealthcare:
• Generally accepted standards of medical
practice.
• Clinically appropriate, in terms of type,
frequency, extent, site and duration, and
considered effective for your sickness,
injury, substance use disorder, disease or
its symptoms.
• Not mainly for your convenience or that of
your doctor or other health care provider.
• Not more costly than an alternative drug,
service(s) or supply that is at least as
likely to produce equivalent therapeutic or
diagnostic results as to the diagnosis or
treatment of your sickness, injury, disease
or symptoms.
Definitions
Network: A group of health care providers, including
dentists, physicians, hospitals and other health care
providers, that agrees to accept predetermined rates
when serving members.
Non-Formulary Drugs: These drugs are not on the
recommended formulary list. These drugs are usually
more expensive than drugs found on the formulary. You
may purchase brand name medications that do not
appear on the recommended list, but at a significantly
higher out-of-pocket cost.
Out-of-Pocket Maximum: The maximum amount of co-
insurance a Plan member must pay toward covered
medical expenses in a calendar year for both network
and non-network services. Once you meet this out-of-
pocket maximum, the Plan pays the entire coinsurance
amount for covered services for the remainder of the
calendar year. Deductibles and copays apply to the
annual out-of-pocket maximum.
PDP Fee: PDP Fee refers to the fees that participating
PDP dentists have agreed to accept as payment in full,
subject to any copayments, deductibles, cost sharing
and benefit maximums.
Portability: A team member carries or “ports” her/his
current Group Life coverage after employment ends,
without having to answer any medical questions.
Portability is for an associate who is leaving her/his
job and still wants to maintain the protection that life
insurance provides.
Pretax Plan: A plan for active team members that is
paid for with pretax money. The IRS allows for certain
expenses to be paid for with tax-free dollars. The
state takes premiums out of your check before taxes
are calculated, increasing your spendable income
and reducing the amount you owe in income taxes.
Consequently, the IRS has tax laws that require you to
stay in the plans you select for a full plan year (January
through December). You can only make changes during
Open Enrollment or if you have a Qualifying Event.
Prior Authorization: Getting approval from
UnitedHealthcare for the recommended medicine,
services or supplies prior to receiving them. Without
this prior approval, your health plan may not provide
coverage, or pay for the medication, services or
supplies. Not all covered health services require
prior authorization.
42
Primary Care Physician (PCP): The health care
professional who monitors your health needs and
coordinates your overall medical care, including
referrals for tests or specialists.
Provider: Any type of health care professional or facility
that provides services under your plan.
Qualifying Event: An occurrence that qualifies the
subscriber to make an insurance coverage change
outside of Open Enrollment.
Reasonable and Customary Charge (R&C): R&C fee refers
to the Reasonable and Customary (R&C) charge,
which is based on the lowest of: (1) the dentist’s actual
charge, (2) the dentist’s usual charge for the same or
similar services, or (3) the charge of most dentists in the
same geographic area for the same or similar services,
as determined by MetLife.
Domestic Partner (as an eligible dependent): A domestic
partnership is a relationship between a team member
and one other person of the same or opposite sex.
Both persons must:
• Not be so closely related that marriage
would otherwise be prohibited;
• Not be legally married to, or the other
domestic partner of, another person under
either statutory or common law;
• Be at least 18 years old;
• Live together and share the common necessities
of life; and
• Be mentally competent to enter into a contract.
Specialty Drugs: Prescription medications that require
special handling, administration or monitoring. These
drugs may be used to treat complex, chronic and often
costly conditions.
Spouse (as an eligible dependent): The person to whom
you are legally married.
Helpful Contact Information
Benefit Program / Provider Website Phone Number

Benefits Service Center

Enrollment (Open Enrollment, New Hire
www.YourBenefitsResources.com/OneMain 800-804-8502
Enrollment & Family Status Changes)
Health & Welfare Benefits Administration

401(k) Plan
Check your account balance, manage your
deferrals, change investments and more. trsretire.com/webportal/springleaf 800-755-5801
Administration and record-keeping services
by Transamerica Retirement Solutions
#JK62892

UnitedHealthcare – Group Number 730727

Choice Plus PPO Plan
Value or Savings Consumer Driven Health
welcometouhc.com/onemain 877-370-0823
Plan (CDHP)
Use “myHealthcare Cost Estimator” to
forecast medical coverage expenses

OptumHealth Bank
www.optumhealthfinancial.com 800-791-9361
Health Savings Account (HSA)

Quit for Life

www.QuitNow.net 866-784-8454
Tobacco Cessation Program

Kaiser
Northern CA – Group Number 603505 kp.org 800-464-4000
Southern CA – Group Number 230920

Hawaii Medical Service (HMSA) – Group

Number 18417-1-7 hmsa.com 808-935-5441
Health Plan Hawaii (HPH)

Express Scripts – Group Number AGF1000

PPO Platinum Rx, Value CDHP Platinum Rx express-scripts.com 877-508-4866
or Savings CDHP Platinum Rx

Express Scripts Prior Authorization esrx.com/pa 1-800-753-2851

MetLife – Group Number 147890 metlife.com/dental

Enhanced Dental Plan Policy / member number is
Preventive Dental Plan 800-942-0854
Team Member number preceded by 00.
Please note: ID cards are not issued. Example: 001234567.

vsp.com
Vision Service Plan (VSP) #30027751
VSP Choice Plan Policy / member number is 800-877-7195
Team Member number preceded by 00.
Please note: ID cards are not issued.
Example: 001234567

43
Helpful Contact Information
Benefit Program / Provider Website Phone Number

The Hartford – Group Number 696961G

Short-term Disability, Long-term www.thehartfordatwork.com 866-958-4069
Disability, FMLA & Bonding Leave

The Hartford – Group Number 696961G

N/A 888-563-1124
Life and AD&D Insurance

Guidance Resources – Company ID 888-381-4327

www.guidanceresources.com
VX3291S TDD: 800-697-0353

WageWorks for Cobra and Direct Bill https://mybenefits.conexis.com 866-206-5751

Your Spending Account (YSA)

Health Care Flexible Spending Account
www.YourBenefitsResources.com/
(FSA) Limited Flexible Spending Account 844-364-7657
OneMain
(FSA) Dependent Day Care FSA
Commuter Spending Account

Critical Illness:
www.metlife.com/business/benefit.
products/voluntary.benefits/accident.
health/critical.illness.html
800-GET-MET8
MetLife Accident:
Voluntary Benefits www.metlife.com/business/benefit- 800-438-6388
products/voluntary-benefits/accident-
health/accident.html

MetLaw (Access Code: 9260040):

www.legalplans.com

ID Watchdog Identity Theft Insurance:

Voluntary Identity Theft Insurance www.idwatchdog.com 866-513-1518

877-PETS-VPI
(877-738-7874)
Nationwide
www.petinsurance.com/OneMain
Voluntary Pet Insurance (Mention
“OneMain” to receive
discounts)

44
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