Providence Engineering - 2023 Benefits Guide

2023 BENEFITS
ENROLLMENT GUIDE

Mark your calendar for
OPEN ENROLLMENT!
October 28th - November 8th
October
28
REMEMBER: Open Enrollment must be completed by the deadline or
you may not be able to enroll yourself and/or your eligible dependents until our
next open enrollment, or a qualifying event occurs.

CONTENTS
4-5 Benefits Overview
6-10 Medical Insurance
11-12 Health Savings Account
13-14 Flexible Spending Accounts
15-16 Dental Insurance
17 Vision Insurance
18 Disability Insurance
19-22
Basic & Voluntary Life and Accidental Death &
Dismemberment Insurance
23 Accident Insurance
24 Cancer Insurance
25-27 Critical Illness Insurance
28 Pet Insurance
29 Open Enrollment Instructions
30 Important Contacts
31-40 Compliance Notices
41 Glossary

BENEFITS OVERVIEW
ENROLLMENT
You can enroll in benefits or change your elections at the following times:
• 30 days prior to your initial eligibility date (as a newly hired employee)
• During the annual benefits open enrollment period
• Within 30 days of experiencing a qualifying life event
BENEFIT OPTIONS
We offer a comprehensive benefits package consisting of:
• Medical Insurance
• Health Savings Account
• Flexible Spending Accounts
• Dental Insurance
• Vision Insurance
• Group Life and AD&D Insurance
• Voluntary Life and AD&D Insurance
• Long-Term Disability Insurance
• Short-Term Disability Insurance
• Voluntary Accident Insurance
• Voluntary Cancer Insurance
• Voluntary Critical Illness Insurance
• Voluntary Pet Insurance
4

BENEFITS OVERVIEW
ELIGIBILITY
Full-time employees working at least 30 hours per week are eligible for
benefits on the first of the month following date of hire. Many of the plans
offer coverage for eligible dependents, including:
• Your legal spouse
• Your children to age 26, regardless of student, marital, or tax-dependent
status (including stepchild, legally adopted child, a child placed with you
for adoption, or a child for whom you are the legal guardian)
• Your dependent children over age 26 who are physically or mentally
unable to care for themselves
CHANGING BENEFITS AFTER OPEN ENROLLMENT
You may pay your portion of your select coverages, and fund the Health
Savings Account and Flexible Spending Accounts, on a pre-tax basis. Due to
IRS regulations, once you have made your elections for the plan year, you
cannot change your benefits until the next annual open enrollment period.
The only exception is if you experience a qualifying event these election
changes must be consistent with the life event.
To request a benefits change, notify Human Resources within 30 days of the
qualifying life event. Change requests submitted after 30 days cannot be
accepted. You may need to provide proof of the life event.
Qualifying life events include, but are not limited to:
• Marriage, divorce, or legal separation
• Birth or adoption of an eligible child
• Death of your spouse or covered child
• Change in your spouse’s work status that affects his or her benefits
• Change in your child’s eligibility for benefits
• Qualified Medical Child Support Order
5

MEDICAL INSURANCE
CARRIER:: Blue Cross Blue Shield of Louisiana
Please refer to the official plan documents for additional information on coverage and exclusions.
Click Link for Video: HDHP PPO Copay
COVERED BENEFITS
Blue Saver
Premier Blue
Individual Family Individual Family
In-Network Deductible $2,000 $4,000 $1,200 $3,000
Annual Out-of-Pocket Maximum $4,400 $8,800 $4,500 $8,000
Lifetime Maximum Unlimited Unlimited
Primary Services Deductible + 20% $30 Copay
Specialist Physician Office Visit Deductible + 20% $50 Copay
Preventive Care Services Covered at 100% Covered at 100%
Urgent Care Center Deductible + 20% $100 Copay
Hospital Services
Emergency Room Deductible + 20% $150 Copay
Outpatient Facility Deductible + 20% Deductible + 20%
MRI, CT, MRA, and PET Deductible + 20% Deductible + 20%
Severe Mental/Nervous
Inpatient Deductible + 20% Deductible + 20%
Outpatient Deductible + 20% $30 Copay
Prescription Drug Benefits
Deductible Embedded with Medical $0
Tier I (Generic) Deductible + 0% $7 Copay
Tier II (Preferred Brand) Deductible + 20% $35 Copay
Tier III (Non-Preferred Brand) N/A $100 Copay
Tier IV (Specialty) N/A 20% up to $250/per Rx
Pharmacy Tier Review: Bcbsla.com/covered drugs
6

WHICH MEDICAL INSURANCE PLAN IS
RIGHT FOR YOU?
Choosing the right medical plan is an important decision. Take the
time to learn about your options to ensure you select the right plan
for you and your family.
THINGS TO CONSIDER
1. Do you prefer to pay more for medical insurance out of your
paycheck, but less when you need care?
2. Or, do you prefer to pay less out of your paycheck, but more
when you need care?
3. What planned medical services do you expect to need in the
upcoming year?
4. Are you able to budget for your deductible by setting aside
pre-tax dollars from your paycheck in an HSA or FSA?
5. Do you or any of your covered family members take
prescription medications on a regular basis?
Here is a short video summarizing the differences in the plans
available:
HDHP VS PPO
Below is an example of how each plan would pay if you
were to have a large claim:
HDHP VS Premier Blue
Cost Example
Example: Claims Totaling $10,000
Plan
Annual Premium
Cost
Deductible Copay 80% Coinsurance
HSA Company
Contribution
Total Annual
Cost
Premier Blue 759.60 $1,200 $50 $3,250 - 5,259.60
Blue Saver 450.96 $2,000 - $2,400 $600 4,250.96
Assumptions: Employee Only Coverage & Claim is In-Network
7

2023 Medical Insurance Premiums
MEDICAL RATES
COVERAGE LEVEL
Blue Saver
Employee
Semi-Monthly Deduction
Premier Blue
Employee
Semi-Monthly Deduction
Employee Only $18.79 $31.65
Employee & Spouse $173.45 $369.66
Employee & Child(ren) $147.44 $314.99
Employee & Family $329.72 $543.81
Providence, on average, contributes $360.92 semi-monthly towards the Premier Blue plan and
$400.54 semi-monthly towards the BlueSaver Plan
8

TELEMEDICINE / VIRTUAL VISITS
When it comes to healthcare, access
is important. You want care that is
convenient, high-quality and
low-cost. But depending on your
condition, going to your personal
physician or an urgent care clinic
might not be your best option. We
are proud to offer telemedicine /
virtual visits.
TREATED THROUGH TELEMEDICINE
Allergies
Cold & Flu Symptoms
Cough
Ear Infection
Pink Eye
Prescription Refills
Respiratory Infection
Sinus Problems / Nasal Congestion
Urinary Tract Infection
And more!
NOT TREATED THROUGH TELEMEDICINE
Sprains, broken bones or injuries requiring bandaging
Anything that needs a hands-on exam
Anything that needs a lab test or X-ray
Chronic conditions
HOW TO REGISTER
● Step 1: Visit www.BlueCareLA.com or download the BlueCare mobile app on your Apple or
Android device.
● Step 2: Create a member account.
● Step 3: Log into that account each time you use BlueCare online or with the app.
9

MEDICAL INSURANCE
CARRIER:: Blue Cross Blue Shield of Louisiana
BCBS Digital ID Card
If you do need to see a doctor in person, you now have the option to present a digital ID
card. You can access your ID card from your mobile device and online through the member
portal. You’ll need to have an online account to access your digital ID card. If you don’t have
an online account, register today at www.bcbsla.com/login.
●
●
From the BCBSLA mobile app, first make sure you have the latest update of the app.
Once you log in, click My ID Card to see the ID cards available to you.
From the Blue Cross member portal, log into your online account at bcbsla.com. You’ll
see My ID Card with a drop down menu of the ID cards available for viewing. You can
also save these as PDF files.
Sample
10

HEALTH SAVINGS ACCOUNT
CARRIER: HealthEquity
If you enroll in the high-deductible health (HDHP) plan, you may be eligible to fund a
Health Savings Account (HSA). An HSA is a personal health care savings account you
can use to pay out-of-pocket health care expenses with pre-tax dollars. Your
contributions are tax free and the money remains in the account for you to spend on
eligible expenses no matter where you work or how long it stays in the account.
WHO IS ELIGIBLE?
You are eligible to open and fund an HSA if:
● You are enrolled in the High-Deductible Health Plan
● You are not covered by a non-HSA plan, health care FSA, or health reimbursement arrangement
● You are not eligible to be claimed as a dependent on someone else’s tax return
● You are not enrolled in Medicare
● You have not received Veterans Administration Benefits in the last three months
HSA EMPLOYER CONTRIBUTIONS
● Providence will help you save by contributing $50 per
month.
● Contributions to a health savings account (including the
employee contributions) cannot exceed the annual IRS
contribution maximums.
● Employees age 55+ by 12/31/2022 may contribute
additional funds to their HSA (up to $1,000 in 2023).
● You must open your HSA through Healthequity to
receive contributions.
PROVIDENCE
CONTRIBUTES $50 TO YOUR
HSA EACH MONTH
$3,850
INDIVIDUAL
$7,750
ALL OTHER
TIERS
$1,000
AGE 55+
CATCH-UP
CONTRIBUTION
11

HEALTH SAVINGS ACCOUNT
CARRIER: HealthEquity
MAXIMIZE YOUR TAX SAVINGS
• Contributions to an HSA are tax-free and can be made through payroll deductions on a pre-tax
basis.
• The money in your HSA (including interest and investment earnings) grows tax-free.
• As long as you use the funds to pay for qualified medical expenses, the money is spent tax-free.
YOU INDIVIDUALLY OWN YOUR HSA
• You own and administer your HSA.
• You determine how much you will contribute to your account and when to use the money to pay
for eligible health care expenses.
• You can change your contributions at any time during the plan year without a qualifying event.
• Like a bank account, you must have a balance in order to pay for eligible health care expenses.
• Keep all receipts for tax documentation.
• An HSA allows you to save and “rollover” money from year to year.
• The money in the account is always yours, even if you change health plans or jobs.
• There are no vesting requirements or forfeiture provisions.
ACCESSING YOUR HSA FUNDS
Debit Card: Draws directly from your HSA and can be used to pay for eligible expenses at your
doctor’s office, pharmacy, or other locations where you purchase health related items or services.
USE YOUR HSA TO PAY QUALIFIED MEDICAL EXPENSES
• You can use your HSA money to pay for eligible expenses now or in the future.
• Funds in your HSA can be used for your expenses and those of your spouse and eligible
dependents, even if they are not covered by the HDHP Plan.
• Eligible expenses include deductibles, doctor’s office visits, dental expenses, eye exams,
prescription expenses and LASIK eye surgery.
• A complete list of eligible expenses can be found at www.irs.gov
• You can also visit this link for for further information from Healthequity: HSA Resource Center
12

FLEXIBLE SPENDING ACCOUNTS
CARRIER: iSolved Benefit Services
Providence offers two Flexible Spending Account (FSA) options – the Health Care FSA and the
Dependent Care FSA – that allow you to pay for eligible health care and dependent care expenses with
pre-tax dollars.
Log into your account at www.isolvedbenefitservices.com to view your account balance(s), calculate
tax savings, view eligible expenses, download forms, view transaction history, and more.
HEALTH CARE FSA
• Set aside pre-tax money from your paycheck to pay for eligible out-of-pocket expenses, such
as deductibles, copays, and other health-related expenses, that are not paid by the medical,
dental, or vision plans.
• Over-the-counter (OTC) medications are eligible for reimbursement without a prescription.
DEPENDENT CARE FSA
• Set aside pre-tax money from your paycheck for daycare expenses when you and your spouse
work or attend school full time.
• Eligible dependents are children under age 13, or a child over 13, spouse, or elderly parent
residing in your house who is physically or mentally unable to care for himself or herself.
• Examples of eligible expenses are daycare facility fees, before and after-school care, and
in-home babysitting fees (income must be reported by your care provider).
Refer to the official Summary Plan Document for a list of eligible expenses to maximize the Value of your Flexible
Spending Account.
HEALTH CARE FSA
$3,050 $5,000
DEPENDENT CARE FSA
$2,500
married filing jointly or
single / head of household
married filing separately
13

FLEXIBLE SPENDING ACCOUNTS
CARRIER: iSolved Benefit Services
HOW DOES AN FSA WORK?
You decide how much to contribute to each FSA on a plan year basis up to the maximum allowable
amounts. Your annual election will be divided by the number of pay periods and deducted evenly on
a pre-tax basis from each paycheck throughout the year.
You will receive a debit card from iSolved Benefit Services, which can be used to pay for eligible health
care expenses at the point of service. If you do not use your debit card or if you have dependent care
expenses to be reimbursed, submit a claim form and a bill or itemized receipt from the provider to
iSolved Benefit Services. Keep all receipts in case iSolved Benefit Services requires you to verify the
eligibility of a purchase. To find further information, you can visit the Isolved FSA resource center at:
Isolved FSA Resource Center
THINGS TO CONSIDER
• Both the healthcare and dependent care FSA dollars are use it or lose it, so be careful to estimate
your eligible medical expenses.
• You cannot take income tax deductions for expenses you pay with your FSA(s)
• You cannot stop or change your FSA contribution(s) during the plan year unless you experience a
qualifying life event.
SPECIAL HEALTH CARE FSA ACCOUNT FEATURES
ROLLOVER
You have the ability to
roll over up to $610
from one plan year to
the next.
14

DENTAL INSURANCE
CARRIER: Sun Life
●
●
●
●
You will pay less out of pocket when you choose an in-network provider.
Locate an in-network provider at www.sunlife.com/us
Be sure to ask for a pre-treatment estimate.
Out-of-network providers can balance bill ( bill you for the difference between
the provider’s charge and the allowed amount).
DENTAL
ELECTION
SEMI-MONTHLY
PAYROLL DEDUCTION
Employee Only $0.00
Employee & Spouse $29.88
Employee & Child(ren) $37.50
Employee & Family $67.67
COVERED BENEFITS
Deductible (per calendar year) Waived for Preventive
Annual Plan Benefit Maximum
Type I - Preventive Care Oral exams, cleanings, X-rays, fluoride treatment(1 in any
6 month period)
Bite-Wing x-Rays (1 in any 12 month period)
Intraoral x-Rays (1 in any 60 month period)
Type II - Basic Services Periodontal & endodontic services, oral surgery, fillings,
simple extractions
Periodontal Maintenance (1 in any 6 consecutive months)
Type III - Major Services Inlays, onlays, crown restoration
Bridges & dentures (10 year replacement limit)
Dental Implants (10 year replacement limit)
PLAN PAYS
$50 per person, $150 per family
$5,000 per covered member
100%
80%
50%
Orthodontia Services (Dependent Children to age 26) 50%
Lifetime Orthodontia Plan Max (Dependent Children to age 26) $1,500
15

Dental Insurance Card
14

VISION INSURANCE
CARRIER: Sun Life
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.vsp.com .
● You must submit a claim form for out-of-network expenses.
● LASIK surgery discounts available.
VISION
ELECTION
SEMI-MONTHLY
PAYROLL DEDUCTION
Employee Only $3.81
Employee & Spouse $7.67
Employee & Child(ren) $8.13
Employee & Family $12.86
COVERED BENEFITS
IN-NETWORK
Eye Exam (every 12 months)
$10 copay
Standard Plastic Lenses (every 12 months)
Standard Progressive
Premium Progressive
Custom Progressive
$25 copay
$25 copay
$95-$105 copay
$150-$175 copay
Frames (every 24 months)
$130 allowance + 20% off balance
$70 allowance at Costco®
Contact Lenses in lieu of standard plastic lenses
(every 12 months)
Up to $60 / 15% savings on your contact lens exam
(fitting and evaluation)
$130 allowance
17

DISABILITY INSURANCE
CARRIER: SunLife
LONG-TERM DISABILITY INSURANCE
Long-Term Disability (LTD) Insurance is automatically provided to all benefitseligible
employees at no cost. LTD Insurance is designed to help you meet your
financial needs during longer disability periods. Benefit may be offset due to other
benefits such as paid sick leave or workers’ compensation.
• Benefit: 60% of base monthly salary up to $10,000 per month
• Elimination Period: 180 days
• Benefit Duration: Until Social Security Normal Retirement Age
• Pre-Existing Condition Waiting Period: 3 month/12 month
VOLUNTARY SHORT-TERM DISABILITY INSURANCE
Short-Term Disability (STD) Insurance is designed to help you meet your financial
needs if you become unable to work due to a non-work related illness or injury.
This is a voluntary plan; employees are responsible for 100% of the cost.
Premiums are calculated as a percentage of your annual base salary. Benefit may
be offset due to other benefits such as paid sick leave or workers’ compensation.
• Benefit: 60% of base weekly salary up to $1,500 per week
• Elimination Period: 7 days, benefit starts on 8th day
• Benefit Duration: Up to 25 weeks
• Pre-Existing Condition Waiting Period: 3 month/12 month
• Portability: included
STD Semi-Monthly Rate per $10 of Weekly Benefit: $0.208
Step 1:
$______________ ÷ 52 (weeks) = $____________
Annual Salary
Weekly Salary
Step 2:
$_____________ X 60% = $_________________
Weekly Salary
Weekly Benefit
Step 3: $_______________________ = (Weekly Benefit X .208) ÷ 10
Semi-Monthly Deduction
*NOTE: You will see your exact Payroll Deduction when you log into Employee Navigator.
1. Annual Salary ÷ 52 = Weekly Salary
2. Weekly Salary * 60% = Weekly Benefit
3. Semi-Monthly Deduction = (Weekly Benefit * .208) ÷ 10
18

GROUP LIFE INSURANCE
CARRIER: Sun Life
LIFE and ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)
Providence provides $50,000 Employer Paid Life and Accidental benefits to all
full-time employees through Sun Life.
The company also offers Basic Life and AD&D for your spouse in the amount of
$10,000 and children over 6 months in the amount of $5,000. If elected, the
premium is $1.03 a paycheck.
● Employee Coverage reduces to 67% at age 70 and 50% at age 75
● Child eligibility – For the voluntary life insurance, child eligibility includes
children up to their 26 th birthday regardless of full time student status. A
reduced benefit of $500 is payable for a child from 14 days - 6 months.
VOLUNTARY LIFE INSURANCE
CARRIER: Sun Life
WHAT IS VOLUNTARY LIFE INSURANCE?
Voluntary Life insurance is offered through an employer
but is paid by employees.
WHY PURCHASE VOLUNTARY LIFE
INSURANCE?
● This type of life insurance has limited
underwriting required. This allows for people
with health conditions or lifestyles that might
otherwise disqualify them to qualify for life
insurance.
● The group rates are lower than what you could purchase on your own.
● You may purchase a policy for your spouse and children IF you elect coverage for yourself.
REMINDER
Review your beneficiary designations
19

VOLUNTARY LIFE INSURANCE
CARRIER: Sun Life
Category
Employee Coverage
Benefit Amount
Benefit Increments
Benefit Maximum
Guaranteed Issue Coverage
Spouse Coverage
Benefit Amount
Benefit Increments
Benefit Maximum
Guaranteed Issue Coverage
Age Reduction Schedule
Age 70
Age 75
Dependent Child Coverage
*Unmarried dependent children from 14 days to
age 21 or to age 24 if full-time student
*Children ages 14 days - 6 months are eligible for
a reduced benefit
Up to 5x Annual Salary
$10,000
$500,000
$100,000
Benefit
Up to 50% Employee Amount
$5,000
$100,000
$25,000
To 67% at Age 70
To 50% at Age 75
$10,000
$500
Notes:
- Rates are age-banded; cost increases with age
- Employee must be enrolled in Supplemental Life Coverage for dependents to enroll in coverage
- Supplemental Life Coverage is portable upon Retirement
- Spouse termination age - 70
- After your initial enrollment, Evidence of Insurability (EOI) is required for additional coverage
Amounts elected over the guaranteed issue amount will require Evidence of Insurability (medical
questions). To complete the evidence of insurability online: https://www.sunlife-usa.net/eoi
REMINDER
Review your beneficiary designations
20

EMPLOYEE VOLUNTARY LIFE INSURANCE
RATES
CARRIER: Sun Life
REMINDER
Review your beneficiary designations
*NOTE: You will see your exact Payroll Deduction when you log into Employee Navigator.
21

DEPENDENT VOLUNTARY LIFE
INSURANCE RATES
CARRIER: Sun Life
*NOTE: You will see your exact Payroll Deduction when you log into Employee Navigator.
22

VOLUNTARY ACCIDENT INSURANCE
CARRIER: Sun Life
Accident Insurance supplements your existing medical insurance in case you have an accident;
medical insurance alone may not be enough to cover your expenses. This plan pays a cash benefit
during the term of your coverage following a covered accident and could help cover:
● Out-of-pocket expenses such as copays and deductibles
● Transportation
● Lodging costs
● Emergency room expenses
Accidental Death $25,000
Accidental Death Common Carrier $100,000
Catastrophic Loss: Both arms or both hands, both legs or both feet, one hand and one foot or
one are and one leg, or irrecoverable loss of sight of both eyes
$15,000
One hand, one foot, one leg, one arm $7,500
Two or more fingers or toes $1,500
One finger or one toe $750
Dislocations Open Closed
Hip $4,000 $2,000
Knee, ankle, or bones of the foot $2,000 $1,000
Shoulder $1,000 $500
Fractures Open Closed
Hip or thigh $4,000 $2,000
Leg $2,000 $1,000
Rib, Finger, Toe or Coccyx $350 $175
Coma $10,000
Concussion $100
Diagnostic Exam: Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI (1 time per benefit year) $200
Diagnostic Exam X-ray (1 time per covered accident) $40
Accident Emergency Treatment, nonemergency room (once per covered accident) $50
Physician's Follow-up Treatment office visit (per visit, up to 6 times per covered accident) $25
Physical Therapy (per visit up to 10 visits per covered accident) $40
Hospital Admission (Once per benefit year) $1,000
Ambulance Ground/Air $200/$1,500
Wellness Screening Benefit (Once per benefit year) $50
ACCIDENT
SEMI-MONTHLY
RATES
PAYROLL DEDUCTIONS
Employee Only $4.63
Employee & Spouse $8.00
Employee & Child(ren) $9.05
Employee & Family $12.42
23

VOLUNTARY CANCER INSURANCE
CARRIER: Sun Life
Cancer Insurance supplements your existing medical insurance in
case you are diagnosed with cancer; medical insurance alone may
not be enough to cover your expenses. This plan pays a cash
benefit during the term of your coverage following a positive
diagnosis of certain cancers.
WHY PURCHASE CANCER INSURANCE?
You and your loved ones can rest a little easier knowing you have
protection inplace to help avoid depleting your bank accounts or
taking on additional debt to cover day-to-day living expenses.
These reimbursements will free up additional monies for:
● Help cover medical plan deductibles, co-pays and other out-of-pocket costs
● Help cover everyday living expenses such as groceries, rent and mortgage payments
● Hire extra help for around the house, such as in-home caregivers
● Pay for travel to treatment facilities away from home as well as family visits
Category
First Occurrence
Pays the amount shown when the insured person is diagnosed for the first time as having internal
cancer. This benefit is only payable once per lifetime.
Benefit
$5,000
Continuous Hospital Confinement (Daily up to 90 days)
$400 daily
Radiation and Chemotherapy
• Injected Cytoxic Medications (weekly)
$1,000
• Pump Dispensed Cytotoxic Medications (first prescription & refill)
$1,000
• Oral Cytotoxic Medications (per prescription)
$500
• Cytotoxic Medications Administered by any other method (weekly)
$1,000
• External Radiation Therapy (weekly)
$600
• Insertion of Interstitial or Intracavitary administration of radioisotopes or Radium (weekly) $750
• Oral or I.V. Radiation (weekly)
$600
Post-hospital Doctor Visits (per visit) $50
Home Health Care (per visit) within 7 days of hospital release and max 30 days per hospital
$50
confinement. Max 90 days per benefit year
Extended Care Facility (paid daily) Max 90 days per benefit year $200
Hospice (paid per day) Max 100 days lifetime $100
CANCER
SEMI-MONTHLY
RATES
PAYROLL DEDUCTIONS
Employee Only $12.48
Employee & Spouse $20.79
Employee & Child(ren) $14.25
Employee & Family $22.56
24

VOLUNTARY CRITICAL ILLNESS INSURANCE
CARRIER: Sun Life
Critical Illness Insurance supplements your existing medical
insurance in case you are diagnosed with a covered condition,
like a heart attack or stroke; medical insurance alone may not
be enough to cover your expenses. The plan pays a cash benefit
during the term of your coverage following a covered diagnosis.
Critical illness insurance may not cover all types of cancer, but it does cover heart and vascular
conditions, cancer-related conditions, and major organ failure.
● Employee Benefit Amount: $5,000 - $30,000 of coverage, in increments of $5,000.
● Employee Benefit Reduction Schedule: 50% at age 70.
●
●
●
●
Spouse Benefit Amount: If you elect coverage for yourself, you can choose $2,500 - $15,000 of coverage,
in increments of $2,500. NOT TO EXCEED 50% OF THE EMPLOYEE COVERAGE AMOUNT.
Spouse Benefit Reduction Schedule: Benefit may be reduced when the employee benefit amount is
reduced.
Child(ren) Benefit Amount: If you elect coverage for yourself, you can choose $2,500 - $5,000 of
coverage. NOT TO EXCEED 50% OF THE EMPLOYEE COVERAGE AMOUNT. Available to Dependent
Child(ren) from birth to age 26.
Child(ren) Benefit Reduction Schedule: Benefit may be reduced when the employee benefit amount is
reduced.
COVERED CONDITIONS - The plan pays 100% of the benefit amount unless stated otherwise.
*Please refer to the official carrier plan summary for all details, limitations, and exclusions.
Core Conditions:
Heart Attack, End-Stage Kidney Disease, Occupational HIV/Hepatitis B, C, or D, Major Organ Failure, Stroke, Coronary
Artery Bypass Graft, Angioplasty.
Other Conditions:
Complete Blindness, Complete Loss of Hearing, Loss of Speech, Benign Brain Tumor, Coma, Severe Burns, Advanced
ALS/Lou Gehrig’s Disease, Advanced Parkinson’s Disease (Pays 25%), Advanced Alzheimer’s Disease (Pays 25%),
Paralysi.
Wellness Screening Benefit:
Payable to any covered person on your plan one time each year, once you provide proof of an eligible health
screening.
Employee: $50
Spouse: $50
Child: $50
25

EMPLOYEE VOLUNTARY CRITICAL ILLNESS
INSURANCE RATES
CARRIER: Sun Life
EMPLOYEE
COVERAGE
AMOUNT
Critical Illness Non Tobacco Semi Monthly Rates

DEPENDENT VOLUNTARY CRITICAL ILLNESS
INSURANCE RATES
CARRIER: Sun Life
SPOUSE
COVERAGE
AMOUNT
Critical Illness Non Tobacco Semi Monthly Rates

PET INSURANCE
CARRIER: Best Pets
Pet Insurance reimburses you for vet bills when your
pet is sick or injured, to help take the financial worry
out of vet visits.
• Fast claims processing and payment
• Optional direct deposit and direct vet pay options
• Use any veterinarian in the U.S., including
specialty and emergency clinics
• Optional coverage for routine care
• Access to a 24/7 pet helpline
HOW IT WORKS
1. Choose a Plan: It only takes 5 minutes. Simple, no medical records to enroll, instant approval, and 30-day
money back guarantee.
2. Get Treatment: When your pet becomes ill or injured, you have the option to take them to any licensed
veterinarian of your choice.
3. File a Claim: You pay their vet bill and then submit a claim. There is no need to send medical records
unless Pets Best requests them.
4. Get Reimbursed: Most claims are processed within 5 business days for quick reimbursement. Get
reimbursed 70%-90% of the actual vet bill after an annual deductible.
Pets Best has setup a custom enrollment path for Providence employees. If you wish to enroll in Pet Insurance,
you can enroll by visiting www.petsbest.com/providence or you can call 888-984-8700.
You must reference the referral code: PROVIDENCE in order to be eligible to receive the discounted premium.
28

OPEN ENROLLMENT INSTRUCTIONS
During the Employee Benefits Enrollment process, representatives from Human Resources and
BXS+Cadence Insurance will be available to answer any questions regarding the benefits package
Providence Engineering offers to eligible employees.
STEP 1: Go to the following link to
create an account as an employee:
https://www.employeenavigator.com/ben
efits/Account/Register
Note: It is recommended you use an email
address for your user name.
STEP 2: You will be asked for personal
identifying data as well as the following
Company Identifier: PROVENGENV
STEP 3: Write down the username and password you created for future reference.
STEP 4: You are now ready to make your benefit elections! Please select the “Start Enrollment”
button. The system will guide you through the process. Be sure to select ‘Save & Continue’ on every
screen. Note: IF you are covering a spouse and /or child, please have their full name, DOB, and SSN
available.
STEP 5: Choose the “Click to Sign” button to complete your enrollment.
Once you have created your account, use the following link anytime to finish or view your benefit
elections: https://employeenavigator.com/benefits/Account/Login
REMEMBER: Open Enrollment must be completed by the deadline or
you may not be able to enroll yourself and/or your eligible dependents until our
next open enrollment, or a qualifying event occurs.
This summary of benefits is not intended to be a complete description of the terms of Providence Engineering, LLC’s insurance benefit plans. Please
refer to the plan document(s) for a complete description. Each plan is governed in all respects by the terms of its legal plan document, rather than by
this or any other summary of the insurance benefits provided by the plan. In the event of any conflict between a summary of the plan and the official
document, the official document will prevail. Although Providence Engineering, LLC maintains its benefit plans on an ongoing basis, Providence
Engineering, LLC reserves the right to terminate or amend each plan, in its entirety or in any part at any time.
29

IMPORTANT CONTACTS
BENEFIT CARRIER PHONE WEBSITE
Medical Insurance
Telemedicine
Blue Cross Blue Shield
of Louisiana
Blue Cross Blue Shield
of Louisiana
800-599-3583 www.bcbsla.com
855-269-3554 www.BlueCareLA.com
Health Savings Account HealthEquity 877-987-8123 www.healthequity.com
Flexible Spending
Account
iSolved Benefit
Services
866-370-3040 www.isolvedbenefitservices.com
Dental Insurance Sun Life 800-442-7742 www.sunlife.com/us
Vision Insurance Sun Life (VSP) 800-786-5433 www.vsp.com
Disability Insurance Sun Life 800-786-5433 www.sunlife.com/us
Group Life Insurance Sun Life 800-786-5433 www.sunlife.com/us
Accident / Cancer /
Critical Illness Insurance
Sun Life 800-786-5433 www.sunlife.com/us
Pet Insurance Pets Best 88-984-8700
www.petsbest.com/providence
Use referral code: PROVIDENCE
Providence Engineering
and Environmental
Group, LLC
Robin Liggett or Liz
Fischer
225-766-7400 humanresources@providenceeng.com
Enrollment Website Employee Navigator n/a www.employeenavigator.com
YOUR CADENCE INSURANCE ACCOUNT REPRESENTATIVE:
(formerly BXS Insurance)
Ashley Fernandes
225-621-0037
ashley.fernandes@cadenceinsurance.com
30

COMPLIANCE
DISCLOSURES
PLEASE NOTE: The attached disclosures must be or should be provided to you
at open enrollment. However, your employer/plan sponsor will likely have
additional disclosure obligations throughout the calendar/plan year. Those
disclosures are not included in this booklet. While Cadence Insurance
(formerly BXS Insurance) may assist your employer in providing the required
disclosures, it is ultimately your employer's responsibility to provide them to
you. Please contact your employer if you have questions or need additional
information.

COMPLIANCE DISCLOSURES
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, contact: Robin Liggett, Providence Engineering, 1201 Main Street, Baton Rouge, LA 70802, P:
225-766-7400, E: robinliggett@providenceeng.com
NEWBORNS’ ACT DISCLOSURE
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for
the mother or newborn child to less than 48 hours following a vaginal 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, from discharging the mother or her newborn earlier than 48 hours (or 96
hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).
Under the law, if your plan provides benefits for obstetrical services, your benefits will include coverage for postpartum services. Coverage will include benefits of
inpatient care and home visit(s), which shall be in accordance with the medical criteria, outlined in the most current version of or an official update to the “Guidelines
for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists or the “Standards for
Obstetric-Gynecologic Services” prepared by the American College of Obstetricians and Gynecologists. Coverage for obstetrical services as an inpatient in a general
Hospital or obstetrical services by a Physician shall provide such benefits with durational limits, deductibles, coinsurance factors and copayments that are no less
favorable than for physical illness generally.
PATIENT PROTECTION NOTICE
BCBSLA generally allows 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 information on how to select a primary care provider, and for a list of the participating primary care providers,
contact your plan administrator listed below.
For children, you may designate a pediatrician as the primary care provider.
You do not need prior authorization from BCBSLA 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 our 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 pre-approved treatment plan, or procedures for making referrals. For a list of
participating health care professionals who specialize in obstetrics or gynecology, contact BCBSLA.
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, 2022. Contact your State for more information on eligibility –
32

COMPLIANCE DISCLOSURES
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) Continued
ALABAMA – MEDICAID
Website: http://myalhipp.com/
Phone: 1-855-692-5447
ALASKA - MEDICAID
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: http://dhss.alaska.gov/dpa/
Pages/medicaid/ default.aspx
ARKANSAS - MEDICAID
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
CALIFORNIA - MEDICAID
Website: Health Insurance Premium Payment (HIPP)
Program http://dhcs.ca.gov/hipp
Phone: 916-445-8322
Fax: 916-440-5676
Email: hipp@dhcs.ca.gov
COLORADO – HEALTH FIRST COLORADO
(COLORADO’S MEDICAID PROGRAM) & CHILD
HEALTH PLAN PLUS (CHP+)
Health First Colorado Website: https://www.heal
thfirstcolorado.com/
Health First Colorado Member Contact Center:
1-800-221-3943/ State Relay 711
CHP+: https://www.colorado.gov/pacific/hcpf/
child-health-plan-plus
CHP+ Customer Service: 1-800-359-1991/ State Relay
711 Health Insurance Buy-In Program
(HIBI): https://www.colorado.gov/pacific/hcpf/
health- insurance-buy-program
HIBI Customer Service: 1-855-692-6442
FLORIDA - MEDICAID
Website: https://www.flmedicaidtplrecovery.com/
flmedicaidtplrecovery. com/hipp/index.html
Phone: 1-877-357-3268
GEORGIA - MEDICAID
A HIPP Website: https://medicaid.georgia.gov/
health-insurance-premium-payment-program-hipp
Phone: 678-564-1162, Press 1 GA CHIPRA Website:
https://medicaid.georgia.gov/programs/third-party-li
ability/childrens-health-insurance-program-reauthoriz
ation- act-2009-chipra
Phone: (678) 564-1162, Press 2
INDIANA – MEDICAID
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/
Phone: 1-877-438-4479
All other Medicaid
Website: https://www.in.gov/medicaid/
Phone 1-800-457-4584
IOWA – MEDICAID AND CHIP (HAWKI)
Medicaid Website: https://dhs.iowa.gov/ime/
members
Medicaid Phone: 1-800-338-8366
Hawki Website: http://dhs.iowa.gov/Hawki
Hawki Phone: 1-800-257-8563
HIPP Website: https://dhs.iowa.gov/ime/members
/medicaid-a-to-z/hipp
HIPP Phone: 1-888-346-9562
KANSAS - MEDICAID
Website: https://www.kancare.ks.gov/
Phone: 1-800-792-4884
KENTUCKY – MEDICAID
Kentucky Integrated Health Insurance Premium
Payment Program (KI-HIPP) Website: https:// chfs
.ky.gov/agencies/dms/member/Pages/kihipp.aspx
Phone: 1-855-459-6328
Email: KIHIPP.PROGRAM@ky.gov
KCHIP Website: https://kidshealth.ky.gov/Pages
/index.aspx
Phone: 1-877-524-4718
Kentucky Medicaid Website: https://chfs.ky.gov
LOUISIANA - MEDICAID
Website: www.medicaid.la.gov or
www.ldh.la.gov/lahipp
Phone: 1-888-342-6207 (Medicaid hotline) or
1-855-618-5488 (LaHIPP)
MAINE - MEDICAID
Enrollment Website: https://www.maine.gov/dhhs
/ofi/applications-forms
Phone: 1-800-442-6003
TTY: Maine relay 711
Private Health Insurance Premium Webpage: https:
//www.maine.gov/dhhs/ofi/applications-forms
Phone: 1-800-977-6740.
TTY: Maine relay 711
MASSACHUSETTS – MEDICAID AND CHIP
Website: https://www.mass.gov/masshealth/pa
Phone: 1-800-862-4840
MINNESOTA - MEDICAID
Website: https://mn.gov/dhs/people-we-serve/
children-and-families/health-care/health-care-pro
grams/programs-and-services/other-insurance.jsp
Phone: 1-800-657-3739
MISSOURI - MEDICAID
Website: http://www.dss.mo.gov/mhd/ participan
ts/pages/hipp.htm
Phone: 573-751-2005
MONTANA - MEDICAID
Website: http://dphhs.mt.gov/MontanaHealthcare
Programs/HIPP
Phone: 1-800-694-3084
NEBRASKA- MEDICAID
Website: http://www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
Lincoln: 402-473-7000
Omaha: 402-595-1178
NEVADA - MEDICAID
Medicaid Website: http://dhcfp.nv.gov
Medicaid Phone: 1-800-992-0900
NEW HAMPSHIRE - MEDICAID
Website: https://www.dhhs.nh.gov/oii/hipp.htm
Phone: 603-271-5218
Toll free number for the HIPP program:
1-800-852-3345, ext 5218
NEW JERSEY – MEDICAID AND CHIP
Medicaid Website: http://www.state.nj.us/human
services/dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index
.html
CHIP Phone: 1-800-701-0710
NEW YORK - MEDICAID
Website: https://www.health.ny.gov/health_care
/medicaid/
Phone: 1-800-541-2831
NORTH CAROLINA - MEDICAID
Website: https://medicaid.ncdhhs.gov/
Phone: 919-855-4100
NORTH DAKOTA - MEDICAID
Website: http://www.nd.gov/dhs/services/medi
calserv /medicaid/
Phone: 1-844-854-4825
OKLAHOMA – MEDICAID AND CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON - MEDICAID
Website: http://healthcare.oregon.gov/Pages/
index.aspx
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
PENNSYLVANIA - MEDICAID
Website: https://www.dhs.pa.gov/Services/Assist
ance/Pages/HIPP-Program.aspx
Phone: 1-800-692-7462
RHODE ISLAND – MEDICAID AND CHIP
Website: http://www.eohhs.ri.gov/
Phone: 1-855-697-4347, or 401-462-0311 (Direct
RIte Share Line)
SOUTH CAROLINA – MEDICAID
Website: https://www.scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA - MEDICAID
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS - MEDICAID
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
UTAH – MEDICAID AND CHIP
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT - MEDICAID
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
VIRGINIA – MEDICAID AND CHIP
Website: https://www.coverva.org/en/famis -select
https://www.coverva.org/en/hipp
Medicaid Phone: 1-800-432-5924
CHIP Phone: 1-800-432-5924
WASHINGTON - MEDICAID
Website: https://www.hca.wa.gov/
Phone: 1-800-562-3022
WEST VIRGINIA - MEDICAID
Website: https://dhhr.wv.gov/bms/
http://mywvhipp.com/
Medicaid Phone: 304-558-1700
CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-
8447)
WISCONSIN – MEDICAID AND CHIP
Website: https://www.dhs.wisconsin.gov/badger
careplus/p-10095.htm
Phone: 1-800-362-3002
WYOMING - MEDICAID
Website: https://health.wyo.gov/healthcarefin/
medicaid/programs-and-eligibility/
Phone: 1-800-251-1269
33

COMPLIANCE DISCLOSURES
PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) Continued
To see if any other states have added a premium assistance program since Jan. 31, 2022, or for more information on special enrollment rights contact:
U.S. Department of Labor
U.S. Department of Health and Human Services
Employee Benefits Security Administration
Centers for Medicare and Medicaid Services
dol.gov/agencies/ebsa
www.cms.hhs.gov
(866) 444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection
displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of
information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of
information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to
penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged
to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S.
Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room
N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023)
THE WOMEN’S HEALTH AND CANCER RIGHTS
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For
individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses; and
• Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore,
the following deductibles and coinsurance apply: [insert deductibles and coinsurance applicable to these benefits]. If you would like more information on WHCRA
benefits, call your plan administrator: Robin Liggett, Providence Engineering, 1201 Main Street, Baton Rouge, LA, 70802, P: 225-766-7400, E:
robinliggett@providenceeng.com.
WOMEN’S HEALTH AND CANCER RIGHTS ENROLLMENT NOTICE
Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of
reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema?
Call your plan administrator at: 225-766-7400 or more information.
34

COMPLIANCE DISCLOSURES
HIPAA PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Name of Health Plan: Providence Engineering
Why is the Plan providing me with this Privacy Notice?
This Notice is being provided to you in accordance with the requirements of the Standards for Privacy of Individually Identifiable Health Information of the Health
Insurance Portability and Accountability Act (the “HIPAA Privacy Rules”). The HIPAA Privacy rules are federal laws that seek to ensure the privacy and confidentiality of
your health information. The HIPAA Privacy Rules require the Plan to take certain actions to protect the privacy of your health information. This Notice has been
prepared to advise you of the uses and disclosures of your Protected Health Information (as defined below) that may be made by the Plan and to advise you of your
rights and the Plan’s legal duties relating to the privacy of your Protected Health Information.
What is Protected Health Information?
Protected Health Information generally is individually identifiable health information, including demographic information, collected from you or created or received by a
health care provider, health care clearinghouse, a health plan or your employer on behalf of a group health plan that relates to:
(1) your past, present or future physical or mental health or condition;
(2) the provision of health care to you; or
(3) the past, present or future payment for the provision of health care to you.
For example, the information included in an explanation of benefits (“EOB”) from the Plan is Protected Health Information. In addition, Protected Health Information
includes genetic information which includes information about your genetic tests or the genetic tests of your family members or the manifestation of a disease in one of
your family members. For example, the fact that your spouse is diagnosed with Type II diabetes is genetic information.
Will the Plan have access to my Protected Health Information?
Yes. As an individual enrolled in the Plan, you should be aware that the Plan may have access to your Protected Health Information from time to time. The Plan may
receive your Protected Health Information in a variety of ways. An example of how the Plan may receive this information is when your healthcare provider, such as your
doctor or your hospital, submits bills for services rendered to you to be paid by the Plan.
When may the Plan use or disclose my Protected Health Information?
The law permits the Plan to use or disclose Protected Health Information to carry out “treatment,” “payment” and other “health care operations”. When the Plan
makes uses or disclosures of your Protected Health Information for treatment, payment or health care operations purposes, the Plan is not required to notify you or
obtain your Authorization (discussed further below).
Treatment: Treatment means the provision, coordination, or management of healthcare and related services by health care providers, including the coordination or
management of health care by a health care provider with a third party (such as an insurer of the Plan), consultation between providers with respect to a patient, and
the referral of a patient for health care from one provider to another. The Plan itself does not engage directly in “treatment” under the HIPAA Privacy Rules. However,
the Plan may interact with a health care provider in treatment transactions.
Payment: Payment means activities undertaken by the Plan to determine eligibility for benefits or fulfill its responsibility for coverage and provision of benefits under
the Plan. Examples of when the Plan might use or disclose Protected Health Information for payment purposes include disclosures to facilitate the payment of claims
made on the Plan by health care providers, the Plan’s activities to obtain or provide reimbursement for the provision of health care, or the Plan’s activities in obtaining
premiums. When the Plan discloses information for payment purposes, the Plan will attempt only to disclose that Protected Health Information which is minimally
necessary to ensure proper and timely payment of claims.
Health Care Operations: The term “health care operations” means those other functions and activities that the Plan performs in connection with providing health care
benefits. Examples of what constitute health care operations during which the Plan might use or disclose your Protected Health Information include activities relating to
creation, renewal or replacement of a contract of health insurance or health benefits, business planning and development relating to the Plan, and compliance with the
HIPAA Privacy Rules. Another example would include the Plan’s use or disclosure of Protected Health Information to better manage its operations, such as when the
Plan discloses information with a vendor or consultant (commonly referred to as a “Business Associate”) to ensure proper accounting and record-keeping relating to the
Plan’s provision of health care benefits. Under contractual agreements with the Plan, Business Associates can receive, create, maintain, use, and disclose your Protected
Health Information, without your consent, but only to assist the Plan with its payment, operations, and other limited purposes.
May the Plan use or disclose my Protected Health Information for other purposes?
Yes. For uses or disclosures of Protected Health Information that are not made for treatment, payment, or health care operations purposes and for which no exception
regarding Authorization applies, the law requires the Plan to obtain your Authorization. An Authorization is your approval for the Plan’s disclosure of your Protected
Health Information to a particular person or entity for a particular purpose. For example, in general and subject to specific conditions, the Plan will not use or disclose
your psychiatric notes. You may revoke an Authorization at any time, but a revocation is not effective if the Plan has already reasonably relied on your Authorization to
make a particular use or disclosure. Examples of when an Authorization would be required include when the uses or disclosures are made to your employer for
disability, fitness for duty or drug testing purposes. Additionally, if you request that the Plan use or disclose your Protected Health Information, the Plan may require
that you sign an Authorization that permits the Plan to honor your request.
When might the Plan make a use or disclosure of my Protected Health Information without my Authorization?
As discussed above, the Plan is not required to obtain your Authorization to use or disclose your Protected Health Information for treatment, payment or health care
operations purposes. Additionally, there are some limited exceptions in which the law allows the Plan to use or disclose your Protected Health Information for purposes
other than treatment, payment, or health care operations without your Authorization. Most of these uses or disclosures are
35

COMPLIANCE DISCLOSURES
HIPAA PRIVACY NOTICE Continued
the types of uses or disclosures of Protected Health Information that may be made without your Authorization and without giving you the opportunity to object include
those made: to avert communicable or spreading diseases; for public health activities; for federal intelligence, counter-intelligence and national security purposes; to
properly assist law enforcement to carry out their duties; when a judge or administrative tribunal orders the release of such Protected Health Information; for cadaveric
organ, eye and tissue donations (where appropriate); to help apprehend criminals; to assist armed forces personnel and operations; for military service, veterans affairs
separation/discharge matters; for coroner/medical examiner purposes; for health oversight purposes (such as when the government requests certain information from
the Plan to determine its compliance with applicable laws); to assist victims of abuse, neglect or domestic violence; to address work-related illness/workplace injuries
and for workers’ compensation purposes; to carry out clinical research that involves treatment where the proper body has determined the importance for doing so; for
FDA-related purposes; for certain health and safety purposes; for funeral/funeral director purposes; to help determine veterans eligibility status; to protect Presidential
and other high-ranking officials; and for reporting to correctional institutions/law enforcement officials acting in a custodian capacity.
There are also several types of uses or disclosures of Protected Health Information that the Plan may make without your Authorization as long as, whenever possible,
you are given an opportunity to agree or object before the Plan makes the use or disclosure. These exceptions are very limited and generally involve the release of a
limited amount of Protected Health Information to aid your family members, close personal friends, or disaster relief personnel in locating you in the event of an
emergency or in case of your incapacity.
Will the Plan disclose my Protected Health Information to my employer?
The Plan has the right to disclose your Protected Health Information to the Plan Sponsor, which is usually your employer, subject to certain limitations. The Plan may
generally disclose to the Plan Sponsor information regarding whether you are enrolled in the Plan and “summary health information,” which means information that
summarizes the claims history and experiences of the individuals enrolled in the plan without specifically identifying you or other plan participants. The Plan may
disclose this information without your Authorization, and the Plan Sponsor may only use the information for its activities relating to its sponsorship of the Plan. For
example, the Plan Sponsor may use this information to seek bids from health insurers or to analyze its health plan expenses. If the Plan Sponsor needs more than
“summary health information” or enrollment information to carry out its responsibilities, then documents that govern the Plan will determine the extent to which
Protected Health Information may be used or disclosed, except that in no case may the Plan Sponsor use or disclose your Protected Health Information for
employment-related decisions or for any other purposes other than as permitted by the Plan documents or by law. Additionally, Plan Sponsors that receive Protected
Health Information from the Plan must make certain certifications to the Plan regarding the uses and disclosures of the information and must ensure that any agents or
subcontractors of the Plan Sponsor agree to the same restrictions and conditions that apply to the Plan Sponsor.
Will the Plan use or disclose my Protected Health Information for marketing, fundraising or other similar purposes?
While the Plan does not anticipate using or disclosing your Protected Health Information for marketing, fundraising or other similar purposes, under the HIPAA Privacy
Rules, the Plan may only make such uses or disclosures with your Authorization, unless the Plan communicates with you face-to-face or provides you with some
promotional gift of nominal value, in which case your Authorization would not be required.
Is the Plan Subject to Other Restrictions Regarding the Use and Disclosure of my Protected Health Information?
The Plan will not:
(1) use your genetic information for underwriting purposes, which includes determining whether you are eligible for benefits; or
(2) directly or indirectly receive payment in exchange for your Protected Health Information unless the Plan obtains a valid authorization from you.
Do I have the right to request additional restrictions on the uses or disclosures of my Protected Health Information?
Yes. You have the right to request additional restrictions relating to the Plan’s use or disclosure of your Protected Health Information beyond those otherwise required
under the HIPAA Privacy Rules. You also have the right to limit disclosures to family members or friends who are involved in your care or payment for your care. For
example, you could ask that the Plan not use or disclose information about a surgery that you had. Although the Plan is not legally required to grant these requests, it is
your right to make such a request. If the Plan agrees to the restriction, it can stop complying with the restriction after providing notice to you. For additional
information or to obtain the proper form for making such a request, please contact the Plan’s Privacy Officer.
May I request that certain communications of my Protected Health Information be made to me at alternate locations?
Yes. The Plan may communicate your Protected Health Information to you in a variety of ways, including by mail or telephone. If you believe that the Plan’s
communications to you by the usual means will endanger you or your health care and you would like the Plan to make its communications that involve Protected Health
Information to you at an alternate location, you may contact the Plan’s Privacy Officer to obtain the appropriate request form. The Plan will only accommodate
reasonable requests and may require information as to how payment, if any, will be handled.
Do I have the right to obtain access to my Protected Health Information?
Generally yes. You have the right to request and obtain access to your Protected Health Information maintained by the Plan unless an exception applies. The Plan may
deny you access to your Protected Health Information if the information is not required to be accessible under the HIPAA Privacy Rules or other applicable law. For
example, you do not have a right to access information compiled by the Plan in anticipation of or for use in a civil, criminal or administrative proceeding.
If the information you request is maintained electronically, and you request an electronic copy, the Plan will provide a copy in the electronic form and format you
request, provided the information may be readily produced in that manner. If not, the Plan will work with you to come to an agreement on form and format. If you and
the Plan cannot agree on an electronic form and format, the Plan will provide you with a paper copy.
The Plan may charge you a reasonable, cost-based fee for copying (including the cost of supplies and labor) any Protected Health Information required to be copied to
adequately respond to your access request, as well as any postage costs and costs associated with preparing an explanation or summary of the Protected Health
Information necessary to adequately respond to your access request (unless otherwise precluded by applicable State or other law). If you would like to request access
to your Protected Health Information, please notify the Plan’s Privacy Officer so that you can complete the appropriate forms.
36

COMPLIANCE DISCLOSURES
HIPAA PRIVACY NOTICE Continued
Do I have the right to request an amendment to my Protected Health Information?
Yes. You have the right to request that the Plan amend your Protected Health Information. The Plan reserves the right to deny or partially deny requests for
amendments that are not required to be granted under the HIPAA Privacy Rules. For example, the Plan may deny a request for amendment when the Protected
Health Information at issue is accurate and complete. If you would like to request an amendment of your Protected Health Information, please notify the Plan’s
Privacy Officer so that you can complete the appropriate forms.
Do I have the right to an accounting of disclosures of my Protected Health Information made by the Plan?
Yes. You have the right to request and obtain a proper accounting of disclosures the Plan has made of your Protected Health Information. The Plan is not required
to account for all uses and disclosures of Protected Health Information that the Plan makes. For example, the Plan is not required to provide an accounting for
disclosures made for treatment, payment, or health care operations purposes or for disclosures made with your Authorization. Additionally, the Plan reserves the
right to limit its accountings to disclosures made after the compliance date of the HIPAA Privacy Rules.
The Plan will provide you with your first accounting at no charge to you. If you request any additional accountings within a 12-month period, the Plan may charge
you a reasonable, cost-based fee. At the time that you request a subsequent accounting, the Plan will provide you with information regarding the fees, and you
will have the opportunity to withdraw or modify your request if you wish to do so. If you would like to request an accounting of your Protected Health
Information, please notify the Plan’s Privacy Officer so that you can complete the appropriate forms.
Do I have the right to receive notice if the privacy or security of my Protected Health Information is compromised?
Yes. In certain circumstances, you have the right to receive notice from the Plan if the privacy or security of your Protected Health Information is compromised.
The notice will describe what occurred, the date of the occurrence (or if later, the date on which the Plan learned of the occurrence), the type of information
involved, actions you should take to protect your information, and actions the Plan is taking to mitigate the harm and reduce the likelihood of recurrence.
If I have an objection to the way my Protected Health Information is being handled, may I file a complaint?
Yes. The Plan has procedures in place for receiving and resolving complaints. If you believe that the Plan has violated your privacy rights or has acted inconsistently
with its obligations under the HIPAA Privacy Rules, you may file a complaint by contacting the Plan’s Privacy Officer. You may send a letter outlining your complaint
to the Privacy Officer or you may call the Privacy Officer and request a complaint form. The Plan requests that you attempt to resolve your complaint with the Plan
via these complaint procedures since the Plan is in the best position to respond to your complaint. However, if you believe the Plan has violated your privacy
rights, you may also file a complaint with the Office of Civil Rights (“OCR”) at the United States Department of Health and Human Services (“HHS”). You may
contact the HHS OCR at: Medical Privacy, Complaint Division, Office of Civil Rights, United States Department of Health and Human Services, 200 Independence
Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201, Voice Hotline Number (800) 368-1019, Internet Address www.hhs.gov/ocr.
It is against the policies and procedures of the Plan to retaliate against any person who has filed a privacy complaint, either with us or with HHS OCR. Should you
believe that you are being retaliated against in any way upon your filing a complaint with us or the HHS OCR, please immediately contact the Plan’s Privacy Officer,
so that the Plan may properly address the issue.
May the Plan amend this Notice?
Yes. The Plan is required to abide by the Notice that is currently in effect; however, the Plan reserves the right to change the terms of this Notice at any time and
to make the new Notice effective for all Protected Health Information maintained by the Plan. If this Notice is amended, you will be provided with a copy of the
new Notice through regular mail, electronic mail, posting at work site, posting on Intranet sites, or by some other reliable method intended to reach all Plan
participants.
May I obtain a paper copy of this Notice?
Yes. If you received this Notice via the Internet or electronic mail, you have the right to request and receive a paper copy of this Notice. If you would like to receive
a paper copy of this Notice, please contact the Plan’s Privacy Officer.
What if I have additional questions that are not answered in this Notice?
If you have any questions, concern or issues relating to the privacy of your Protected Health Information that is not covered in this Notice, please contact the
Plan’s Privacy Officer.
How do I contact the Plan’s Privacy Officer?
You may contact the Plan’s Privacy Officer by calling Robin Liggett at 225-766-7400 or writing to:
Providence Engineering
1201 Main Street
Baton Rouge, LA 70802
What is the effective date of this Notice?
This Privacy Notice is effective as of January 1, 2023
37

COMPLIANCE DISCLOSURES
MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE LANGUAGE FOR USE ON OR AFTER APRIL 1, 2011 OMB 0938-0990
IMPORTANT NOTICE FROM Providence Engineering ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage and about your options
under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering
joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare
prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan
or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of
coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Providence Engineering has determined that the prescription drug coverage offered by the BCBSLA is, on average for all plan participants, expected to pay out as
much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable
Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th .
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment
Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your coverage may be affected.
If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents may not be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Providence Engineering and don’t join a Medicare drug plan within 63 continuous days after
your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary
premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may
consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare
prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug
plan, and if this coverage through BCBSLA changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the
mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number)
for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social
Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when
you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Date: January 1, 2023
Name of Sender: Providence Engineering
Contact: Robin Liggett
Address: 1201 Main Street, Baton Rouge 70802
Phone number: 225-766-7400
Email address: robinliggett@providenceeng.com
38

COMPLIANCE DISCLOSURES
Model General Notice of COBRA Continuation Coverage Rights
(For use by single-employer group health plans)
** Continuation Coverage Rights Under COBRA**
Introduction
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA
continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available
to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other
coverage options that may cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation
coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights
and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health
Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.
Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan
generally doesn’t accept late enrollees.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific
qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”
You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan,
qualified beneficiaries who elect COBRA continuation coverage may pay or COBRA continuation coverage.
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
●
●
Your hours of employment are reduced, or
Your employment ends for any reason other than your gross misconduct.
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
●
●
●
●
●
Your spouse dies;
Your spouse’s hours of employment are reduced;
Your spouse’s employment ends for any reason other than his or her gross misconduct;
Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:
The parent-employee dies;
●
●
●
●
●
The parent-employee’s hours of employment are reduced;
The parent-employee’s employment ends for any reason other than his or her gross misconduct;
The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
The parents become divorced or legally separated; or
The child stops being eligible for coverage under the Plan as a “dependent child.”
When is COBRA continuation coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The
employer must notify the Plan Administrator of the following qualifying events:
●
●
●
The end of employment or reduction of hours of employment;
Death of the employee;
The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child),
you must notify the Plan Administrator within 60 days [or enter longer period permitted under the terms of the Plan] after the qualifying event occurs. You must
provide this notice to: Robin Liggett, Providence Engineering at 1201 Main Street, Baton Rouge, LA 70802 or you may call 225-766-7400.
How is COBRA continuation coverage provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries.
Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf
of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.
39

COMPLIANCE DISCLOSURES
Model General Notice of COBRA Continuation Coverage Rights Continued
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work.
Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
Disability extension of 18-month period of COBRA continuation coverage
If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and
your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to
have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation
coverage.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up
to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This
extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled
to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent
child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first
qualifying event not occurred.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace,
Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special
enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?
In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have
an 8-month special enrollment period [1] to sign up for Medicare Part A or B, beginning on the earlier of
●
●
The month after your employment ends; or
The month after group health plan coverage based on current employment ends.
If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in
coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage
ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage
may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.
If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay
second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.
For more information visit https://www.medicare.gov/medicare-and-you.
[1]
https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods.
If you have questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information
about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws
affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your
area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information
about the Marketplace, visit www.HealthCare.gov.
Keep your Plan informed of address changes
To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of
any notices you send to the Plan Administrator.
Plan contact information
Robin Liggett, Providence Engineering, 1201 Main Street, Baton Rouge, LA, 70802, P: 225-766-7400, E: robinliggett@providenceeng.com.
40

GLOSSARY
Coinsurance: Your share of the cost of a covered health care service, calculated as a percent (for example, 20%)
of the allowed amount for the service, typically after you meet your deductible. For instance, if your plan’s
allowed amount for an office visit is $100 and you’ve met your deductible (but haven’t yet met your
out-of-pocket maximum), your coinsurance payment of 20% would be $20. Your plan sponsor or employer
would pay the rest of the allowed amount.
Copay: The fixed amount, as determined by your insurance plan, you pay for health care services received.
Deductible: The amount you owe for medical services before your medical insurance or plan sponsor
(employer) begins to pay its portion. For example, if your deductible is $3,000, your plan does not pay anything
until you’ve met your $3,000 deductible for covered health care services. This deductible may not apply to all
services, including preventive care. Preventive care is 100% covered by the plan.
Employee Contribution: The weekly amount you pay for your insurance coverage.
Explanation of Benefits (EOB) / Personal Health Statement (PHS): A statement sent by your insurance carrier
that explains which procedures and services were provided, how much they cost, what portion of the claim was
paid by the plan, and what portion is your liability, in addition to how you can appeal the insurer’s decision.
These statements are also posted on the carrier’s website for your review.
Flexible Spending Accounts (FSA): An option that allows participants to set aside pre-tax dollars to pay for
certain qualified expenses during a specific time period (usually a 12-month period).
Health Care Cost Transparency: Also known as Market Transparency or Medical Transparency. Health care
provider costs can vary widely, even within the same geographic area. To make it easier for you to get the most
cost-effective health care products and services, online cost transparency tools, which are typically available
through health insurance carriers, allow you to search an extensive national database to compare costs for
everything from prescription drugs and office visits to MRIs and major surgeries.
Health Savings Account (HSA): A personal health care bank account funded by you or your employer’s tax-free
dollars to pay for qualified Medical expenses. You must be enrolled in a HDHP to open an HSA. Funds
contributed to an HSA roll over from year to year and the account is portable, meaning if you change jobs, your
account goes with you.
High Deductible Health Plan (HDHP): Plan option that provides choice, flexibility and control when it comes to
spending money on health care. Preventive care is covered at 100% with in-network providers, there are no
copays, and all qualified employee-paid Medical expenses count toward your deductible and your out-of-pocket
maximum.
In-Network: In-network providers are doctors, hospitals and other providers that contract with your insurance
company to provide health care services at discounted rates.
Out-of-Network: Out-of-network providers are doctors, hospitals and other providers that are not contracted
with your insurance company. If you choose an out-of-network doctor, services will not be provided at a
discounted rate and your cost sharing (deductibles and coinsurance) will increase.
Out-of-Pocket Maximum: The maximum amount of money you will pay for medical services during the plan
year. The out-of-pocket maximum is the sum of your deductible and coinsurance payments.
41

Prepared by:
Prepared for:
PROVIDENCE ENGINEERING AND
ENVIRONMENTAL GROUP, LLC