2018 Employee Benefits at A Glance

Benefits at a Glance
2018
Medical
Health Reimbursement Arrangement
Dental
Vision
Flexible Spending
Commuter Benefits
Life Insurance
Short Term Disability
Long Term Disability
Work Life Program
Optional Life Insurance
Optional Disability
Optional Critical Illness
Optional Accidental Injury Insurance
Retirement
Paid Time Of
Enrolling in Benefits
Important Legal Notices
PAGE 2 SAMARITAN DAYTOP VILLAGE - BENEFITS
2018
Benefit Eligibility Employee

Cost
Medical & Full time and part time employees working a minimum See below
of 30 hours per week. Eligibility starts 90 days from
Pharmacy your date of hire.
Samaritan offers one medical plan through Emblem and pharmacy coverage through Express Scripts. If you
enroll in the medical plan, your medical and prescription drug ID cards will be mailed to your home.
Emblem InBalance EPO Medical
The Samaritan medical plan does not cover services performed by out of network providers or facilities. The
plan does not require referrals to see a specialist. The Plan uses the Emblem InBalance EPO network and
you are responsible for verifying network participation before you schedule an appointment to see a
provider.
Express Scripts Pharmacy
Prescriptions will be handled by Express Scripts. You will receive a separate ID card for prescriptions. Express
Specialty medications will be handled by Payer Matrix. If you require a specialty medication please contact
Payer Matrix to assist with fulfilling your specialty medication. In most cases they will also contact you
directly. Payer Matrix can be reached at (877) 305-6202 and Express Scripts can be reached at (800) 282-
2811.
Benefits Snapshot
*Deductible Reimbursement is processed through CHOICE HRA. See page
3 for more details.
Benefit Type Out of Pocket Expense

Primary Office Visit $20 copay (no deductible)
Specialist Office Visit $20 copay (no deductible)
Routine Preventative No Charge
Care
X-Ray/Lab Work No Charge
2018 Payroll Deductions (Pre-
(except hospital or tax)
facility) Base Plan $1,500 Deductible
Emergency $200 ER copay / $20 Urgi-Center ($3,500 HRA Reimbursement)
Copay (no deductible) Annual Employe Employee Employee Employee
Hospital/Surgical Salary e Only & Children & Spouse* & Family
Advanced Diagnostic $5,000 Single Annual Deductible
Testing/Lab billed by $10,000 Family Annual Deductible Up to $35.71 $67.85 $118.73 $178.10
facility $30,000
Your Deductible Base Plan: Buy-up
Responsibility $1,500 $500 $30,001 $44.63 $84.81 $152.66 $228.99
Deductible Base Plan: Buy-Up: to
Reimbursement $3,500 $4,500 ($9,000 $60,000

(HRA) ($7,000 Family
High Plan
$60,001 Buy-up$118.73
$62.48 $500 Deductible
$169.62 $254.43
Family Maximum)*
Maximum)* to
00 HRA($4,5
Prescription $15 Generic copay, $25 Preferred $90,000
brand copay
Reimbursement)
Over $89.27 $169.62 $186.58 $279.86
$50 Non preferred brand copay Annual Employe Employee Employee Employee
(no deductible) Salary e Only & Children & Spouse* & Family
Up to $39.93 $72.08 $126.14 $182.34

There are two easy ways to find providers:
$30,000
1) Call Emblem at 1-877-842-3625 $30,001 $49.92 $90.10 $162.17 $234.28

to
2) Access the online directory at $60,000
https://www.emblemhealth.com/Find-a-Doctor
$60,001 $69.88 $126.14 $180.19 $261.83
to
$90,000
The “Benefits at a Glance” is only a summary of benefits and eligibility and does not guarantee coverage. For more details on coverage, eligibility and limitations please refer to
the summary plan document which can be obtained from Human Resources.
Over $99.84 $180.19 $198.21 $290.44

PAGE 3 SAMARITAN DAYOP VILLAGE - BENEFITS
2018
Benefit Eligibility Employee Cost
Health Employees and Included with Medical

dependents enrolled in
ReimbursementArran the SVI Emblem Medical
gement (HRA) Plan
What is an HRA?
A Health Reimbursement Arrangement is an employer funded
account that reimburses you for part of your in-network
expenses that are applied to your Emblem Medical Plan Annual
Deductible. Active participants in our Emblem Medical Plan are
automatically enrolled in the HRA.
How Does The HRA Work?

After you meet your deductible responsibility (either the first $1,500 for the base plan or the first $500 for
the Buy-Up Option) the HRA will reimburse you for any remaining deductible expenses provided that the
service was rendered by an in-network provider. Emblem Health will pay for any expenses after your
$5,000 or $10,000 deductible is met.
Base Plan HRA

EMBLEM PLAN DEDUCTIBLE $5,000 / PER PERSON / $10,000 FAMILY MAXIMUM
SAMARITAN HEALTH REIMBURSEMENT ACCOUNT $3,500 INDIVIDUAL / $7,000 FAMILY
YOUR RESPONSIBILITY FIRST $1,500 PER PERSON / $3,000 FAMILY
MAXIMUM
ADMINISTRAITOR/CLAIMS PROCESSOR CHOICE STRATEGIES
High Plan Buy-UP HRA

EMBLEM PLAN DEDUCTIBLE $5,000 / PER PERSON / $10,000 FAMILY MAXIMUM
SAMARITAN HEALTH REIMBURSEMENT ACCOUNT $4,500 INDIVIDUAL / $9,000 FAMILY
YOUR RESPONSIBILITY FIRST $500 PER PERSON / $1,000 FAMILY
MAXIMUM
ADMINISTRAITOR/CLAIMS PROCESSOR CHOICE STRATEGIES
How to Receive Reimbursements from the HRA
You must submit a claim to Choice Strategies to receive a reimbursement. You can submit claims via fax, their
website and even smartphone. You will need an Explanation of Benefits (EOB) from Emblem showing that you
had medical services that applied to your deductible.
1) Download Emblem EOB showing that you had medical service that was subject to deductible.
https://www.emblemhealth.com/Members
2) Register with Choice Strategies online and upload the EOB directly on the website below:
https://www.mywealthcareonline.com/choice-strategies
a. Your Employee ID is your Social Security Number

Contact CHOICE by phone
b. The Employer ID is at: (888) 278-2555 option 2
CHOSAMARVILL
OR
1) Download HRA claim forms at: http://www.choice-strategies.com/member-forms
2) Submit completed claim form and Emblem EOB via fax to 1-888-415-6471 or US Mail: Choice
Strategies, P.O. Box 2205, South Burlington, VT 05407
The benefits guide is only a summary of benefits and eligibility and does not guarantee coverage. For more details on coverage, eligibility and limitations please refer to the
summary plan document which can be obtained from Human Resources.
Benefit Eligibility Employee Cost 2018
Dental Full time and part time employees Low Cost Option Plus Buy
working a minimum of 30 hours per week Up Option
Eligibility starts 90 days from your date of
hire.
Samaritan offers two dental 2018 Payroll Deductions (Pre-tax)

plans through Cigna, DHMO
and PPO. The DHMO is the Employee Employee Employee Employee
base option and is offered Only & & & Family
at a low cost to our Children Spouse*
employees and their DHMO $2.06 $5.61 $5.61 $5.61
dependents. The PPO is the
buy-up option (see costs at PPO $10.21 $28.51 $28.51 $28.51
right). *Must be legally married. Domestic Partners are not covered.
Benefits Snapshot
Cigna Dental DHMO Benefit Type DHMO PLAN PPO PLAN
This dental plan uses the Cigna DHMO Network. This
option does not cover out-of-network services. The Annual Plan Unlimited $1,500
network is smaller than the PPO option, but it does Maximum (the
have an unlimited annual benefit and lower out of
most this plan
pocket costs to you for services. You must select a
primary dentist on the ADP portal before your first will pay in a year)
visit. ID Cards will be mailed to you after a primary Annual None $50/Individual
care dentist is selected. Deductible $150 Family
Preventative & No Charge No Charge
Cigna Dental Advantage Diagnostic Care
PPO (Exams,
This dental plan uses the Cigna PPO Advantage Cleanings, X-
network which has a larger selection of providers than rays)
the DHMO. The PPO also provides coverage with out- Basic Care Root Canal: $170 In-Network: No
of-network dentists. You do not have to choose a (Fillings, Root Copay Charge
primary dentist. The plan has an annual maximum Canals, Oral Out-of Network:
payout of $1,500 per calendar year. Out of pocket Surgery, See patient charge Covered at 80%*
expenses are generally higher for you than the DHMO.
Anesthetics) schedule
You will not automatically receive an ID Card. ID cards
can be printed at www.mycigna.com. Go to dental
page and click ‘Print Dental ID Card’.
Major Care Porcelain Crown: In-network: covered
(crowns, $225 Copay at 60%
Finding Dental Providers dentures, Out-of-network:
bridges, See patient charge Covered at 50%*
1. Call Cigna at 1-800-Cigna24 prosthesis over schedule
1-800-244-6224 implant)
Orthodontia 24 months Covered at 50% up
2. Access the online directory at maximum lifetime to $1,000 per
http://hcpdirectory.cigna.com/we benefit. lifetime*
b/public/providers See patient charge
schedule for out of
pocket.
Benefits Questions or Issues?
*Out of network payment are based on 90th percentile of usual and customary charges.
Latoya Belizaire Sarah Clarke Limitations: 1 exam per 6 month period. 1 cleaning per 6 month period, Routine x-ray
bitewing per 12 months. Crowns, Dentures and Bridges are covered once every 5 years.
Samaritan Daytop Village OneGroup NY
(718) 206-2000 ext. 1324 (718) 897-3903 ext. 15
latoya.belizaire@samaritanvillage.or sclarke@onegroup.com
g
2018
Benefit Eligibility Employee Cost
Vision Full time and part time employees working See below
a minimum of 30 hours per week Eligibility
starts 90 days from your date of hire.
2018 Payroll Deductions (Pre-tax)

Employee Employee Employee Employee
Only & & & Family
Children Spouse*
Vision $3.93 $7.85 $7.92 $12.65
*Must be legally married. Domestic Partners are not covered.
Cigna Vision PPO

Provides coverage within the Cigna VSP
Network and also offers coverage outside of
Benefits Snapshot
theSamaritan
network. IDoffers
Cardsawill
vision plan to you
be mailed Benefit Type In-Network Out-of-Network
through Cigna.
after your initial enrollment. Dependents
receive ID Cards, but the employee’s name is Exam $10 Copay $45
displayed on the card. Once per cal. Reimbursement
year
Finding Vision Providers Lenses $20 Copay Single Vision: Up to
Once per $32
1. Call Cigna at 1-800-Cigna24 calendar year Bifocal: Up to $55
1-800-244-6224 Trifocal: Up to $65
Lenticular: Up to
2. Access the online directory at $80
http://hcpdirectory.cigna.com/web/ Contacts Covered up to Reimbursement
public/providers Once per $130 up to $105
calendar year
Submitting Claims Frames Covered up to Reimbursement
In-Network: Simply present your Cigna Allowance $130 up to $71
Vision card to the provider and pay the Once per
calendar year
applicable copay.
Lens Options 20% Savings Not covered
on additional
Out of Net: Download a Cigna Vision
options
Claim form at mycigna.com and send Limitations: Prescription sunglasses are not covered. See plan summary for additional
the completed form and an itemized limitations.
receipt to:
Cigna Vision
Claims Department
PO Box 997561,
Sacramento, CA 95899-7561

Latoya Belizaire Sarah Clarke
(718) 206-2000 ext. 1324 (718) 897-3903 ext. 15
summary plan document which can be obtained from Human Resources. g
2018
Benefit Eligibility Employee Contributions
Flexible Full time and part time employees Decided by employee

working a minimum of 30 hours per
Spending week. Eligibility starts 90 days from
(FSA) & your date of hire.
Commuter *
Now with Choice Debit Card!

A Flexible Spending (FSA) & Commuter
is a great way to save money. It
allows you to set aside tax-free money
to pay for certain out of pocket
expenses. You elect an amount to be
deducted from your paycheck before
taxes are deducted and use that
money to pay for eligible expenses.
Once you sign up, a Choice Debit
Card will be mailed to your home.
You can pay for expenses upfront, Benefit Eligible Monthly
without having to wait for the Expenses Maximum
reimbursement!
Contribution
Medical FSA Medical, Dental, $220.83
Medical FSA Vision
Set aside up to $2,650 per year in pre-tax funds to
pay for medical, dental and vision care expenses. Dependent Child Day Care $416.66
Plan allows you to roll-over a maximum of $500 of Care FSA
unused funds into following plan year. All other
funds are Use-It-Or-Lose-It and will be lost at the
Commuter Parking, Train, Parking: $260
end of the year. Benefits Bus Transit: $260
Dependent Care FSA How it works

Set aside tax free funds to pay for dependent care 1) Decide how much to contribute annually or monthly and
services while you are at work. Services must be
funds will automatically be deducted from your paycheck
for your legal IRS dependents who are 12 or
younger. Funds are not available on the choice debit before taxes.
card.
2) You will have the option to pay for your FSA or commuter
expenses by utilizing your Choice Debit Card*. No out-of-
Commuter Benefits pocket expenses required.
Save on your commute to work. If you take public
transportation to work or pay for parking, a 3) You can also elect to pay out of pocket by going to
Commuter Account saves you money by paying for http://choice-strategies.com to file a claim for
transit and parking expenses with pre-tax dollars.
reimbursement. Claim forms are also located on the
This benefit lowers your taxable income.
Resources Page of the ADP portal.
* Eligible for commuter benefits on 1st day of
employment. Benefits start 1st of the month, if 4) Verify claim by submitting your receipt to Choice
enrollment is received by the 15th of the prior month Strategies.
Contact CHOICE by Phone: (888) 278-2555 option 2

*Register online with Choice Strategies by going to
https://www.mywealthcareonline.com/choice-
strategies
(718) 206-2000 ext. 1324 (718) 897-3903 ext. 15
Employer ID: CHOSAMARVILL
Employee ID: Your Social Security Number
g
2018
Ancillary Benefits
Employee Assistance Program (EAP)
Unum Full time and Company Confidential, counseling sessions by
Work-Life Balance part time Pays master’s level consultants who help with:
employees Locating childcare/eldercare services.
working a Financial issues such as budgeting,
minimum of 30 controlling debt, investing and retirement.
hours per week Assist with complex issues such as
and their relationships, depression, or substance
dependents. abuse as well as legal consultations.
Learn more at www.lifebalance.net
Eligibility starts
Work/Life Hotline 1-800-854-1446
90 days from
your date of
(Spanish 1-877-858-2147)
hire. A wallet card is available in the HR dept.
Life Insurance
Unum Full time and Company Group term policy equal to 2 times
Basic Life & AD&D part time Pays your annual salary with a minimum
employees
working a
of $80,000 and maximum of
minimum of 30 $250,000
Unum hours per week You Pay Group Term Life insurance options
Supplemental Life for you, your spouse and
Eligibility starts dependents. Call 1-800-Ask-Unum
90 days from
your date of with questions.
hire.
Disability Insurance
Short Term All employees Company 50% of your weekly salary up to a
Enhanced (NYS after 4 Pays maximum of $255/week. Benefits
consecutive
DBL) weeks of
start after 7 days of disability.
employment
Unum Full time and part
time employees
60% of salary up to $10,000/month.
Long Term working a Benefits start after 90 days of
Disability (LTD) minimum of 30 disability.
hours per week.
Eligibility starts 90
days from your
date of hire.
Optional Additional Insurances – Call Premier Worksite Benefits (866) 463-
8808 or support@premierworksite.com for more details and enrollment
Accidental Injury Enrollment You Pay Pays you cash for injury treatment.
opportunitie
Critical Illness s available Pays a lump sum if diagnosed with a
during Open specified disease.
Whole Life Enrollment. Permanent Life Insurance that builds
Insurance cash value.
Disability Provides additional income if you
could not work for health reasons.
2018
Other Benefits
Mass Mutual Full time and part You Pay Employees are eligible to contribute
401k time employees. up to $18,500 per year into the Mass
Retirement Eligibility starts 1st of Mutual retirement account. If you
Plan the month following are over 50 there is an additional
90 days of
$6,000 catch-up option.
employment. Must
be at least 21 years You are automatically enrolled in the
of age.
plan with a 4% contribution unless
you decline the plan on the ADP
portal or elect a different
percentage.
You must elect at least 4% to

become eligible for a 1% company
match of .25% for every 1% you
contribute to a max of 4%.
You must make your election on

the ADP portal as well as enroll
on Mass Mutual’s
www.retiresmart.com website.
All Full time and part Company Samaritan Daytop Village contributes
time employees Pays a minimum of 4% towards your
having 1 full fiscal retirement account.
year of service Hires prior to 12/31/2015 become
eligibility
100% vested after 3 years.
Hires after 1/1/2016 become 100%
vested after 5 years.
*Former Daytop employees who were transferred to Samaritan Daytop Village on 11/1/15 will use their
transfer date as their date of hire for the purpose of the 401(k) plan.
Paid Time Of
Paid time off for part time employees will be prorated based on the base number of hours
worked.
Vacation Employees are eligible for a minimum of 3 weeks of vacation per fiscal
year.
Holiday Employees are eligible for 10 holidays per calendar year.
Personal Time Employees are eligible for 2 personal days per fiscal year.
Sick Time
PAGE 9 Employees are eligible for a minimum of 12 sick
SAMARITAN daysVILLAGE
DAYOP per fiscal year.
- BENEFITS
2018
2018
Enrolling in Benefits
Below you will find the steps necessary to complete your benefits enrollment on ADP. All employees must enroll in or
decline their benefits on-line. This includes part-time employees of less than 30 hours eligible for the 401k plan.
To enroll in your benefits:
1) Log on to the ADP Portal Website

www.portal.adp.com Login page:
a) Select User Login b) Enter Login/User Name
c) Enter Password d) Click OK
A quick link to get into the Enrollment page is shown

on the Welcome screen. Click on the link shown next
to the blue arrow.
An Enrollment wizard will walk you through each step.
If enrolling for the first time select
 Walk me through this process
If making changes, select

 I know the changes I want to make
If adding a dependent for the first time, be prepared to

enter their social security number. If your dependent
is already listed, you may skip this step.
You can check your progress while you make
changes, or stop in the middle to return later, and the
system will remember where you left off.
When you are finished making changes, click on
Submit to the Administrator then you will be
prompted to View/Print Summary of Changes for a
print out of your elected benefits. You can log out of
the ADP Portal by clicking Logout on the top
navigation bar.
If you have any questions using the ADP Portal
Website, or if you’ve made an enrollment error, please
contact members of the HR Department
718-206-2000:
Latoya Belizaire x 1324

latoya.belizaire@samaritanvillage.org
Monique Scott x1292
Monique.scott@samaritanvillage.org
Yelena Agranovskiy x 1233

Yelena.Agranovskiy@SamaritanVillage.org
2018
Important Legal Notices – Special Enrollment & WHCA

Special Enrollment Notice
Notices
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” or any
longer period that applies under the plan 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 Latoya

Belizaire, HR Benefits Administrator at (718) 206-2000 extension 1324, or
latoya.belizaire@samaritanvillage.org.
Woman’s Health and Cancer Act

Enrollment & Annual Notice
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. If you would like more information on WHCRA benefits, call your
plan administrator Latoya Belizaire, (718) 206-2000 extension 1324
The “Benefits at a Glance” is only a summary of benefits and eligibility and does not guarantee coverage. For more details on coverage,
eligibility and limitations please refer to the summary plan document which can be obtained from Human Resources.
2018
Important Legal Notices -

Premium Assistance Under Medicaid and the
Children’s Health Insurance Program
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, 2015. Contact
your state for more information on eligibility –
ALABAMA – Medicaid GEORGIA – Medicaid

Website: www.myalhipp.com Website: http://dch.georgia.gov/
Phone: 1-855-692-5447 - Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
The benefits guide is only a summary of benefits and eligibility and does not guarantee coverage. For more details on coverage, eligibility and
limitations please refer to the summary plan document which can be obtained from Human Resources.
2018

(continued)
ALASKA – Medicaid INDIANA – Medicaid
Website: Website: http://www.in.gov/fssa
http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone: 1-800-889-9949
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
COLORADO – Medicaid IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf Website: www.dhs.state.ia.us/hipp/
Medicaid Customer Contact Center: 1-800-221-3943 Phone: 1-888-346-9562
FLORIDA – Medicaid KANSAS – Medicaid
Website: https://www.flmedicaidtplrecovery.com/ Website: http://www.kdheks.gov/hcf/
Phone: 1-877-357-3268 Phone: 1-800-792-4884
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://chfs.ky.gov/dms/default.htm Website:
Phone: 1-800-635-2570 http://www.dhhs.nh.gov/oii/documents/hippapp.pd
f
Phone: 603-271-5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website:
Phone: 1-888-695-2447 http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website:
http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
MAINE – Medicaid NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/publicassistance/ Website:
index.html http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-977-6740 Phone: 1-800-541-2831
TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid

Website: http://www.mass.gov/MassHealth Website: http://www.ncdhhs.gov/dma
Phone: 1-800-462-1120 Phone: 919-855-4100
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid

Website: http://www.dhs.state.mn.us/id_006254 Website:
Click on Health Care, then Medical Assistance http://www.nd.gov/dhs/services/medicalserv/medic
Phone: 1-800-657-3739 aid
Phone: 1-800-755-2604
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP
Website: Website: http://www.insureoklahoma.org
http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 1-888-365-3742
Phone: 573-751-2005
2018

(continued)
MONTANA – Medicaid OREGON – Medicaid
Website: http://medicaid.mt.gov/member Website: http://www.oregonhealthykids.gov
Phone: 1-800-694-3084 http://www.hijossaludablesoregon.gov
Phone: 1-800-699-9075
NEBRASKA – Medicaid PENNSYLVANIA – Medicaid
Website: www.ACCESSNebraska.ne.gov Website: http://www.dpw.state.pa.us/hipp
Phone: 1-855-632-7633 Phone: 1-800-692-7462
NEVADA – Medicaid RHODE ISLAND – Medicaid
Medicaid Website: http://dwss.nv.gov/ Website: www.ohhs.ri.gov
Medicaid Phone: 1-800-992-0900 Phone: 401-462-5300
SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP
Website: http://www.scdhhs.gov Medicaid Website:
Phone: 1-888-549-0820 http://www.coverva.org/programs_premium_assista
nce.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assista
nce.cfm
CHIP Phone: 1-855-242-8282
SOUTH DAKOTA – Medicaid WASHINGTON – Medicaid
Website: http://dss.sd.gov Website:
Phone: 1-888-828-0059 http://www.hca.wa.gov/medicaid/premiumpymt/pa
ges/
index.aspx
Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: https://www.gethipptexas.com/ Website: www.dhhr.wv.gov/bms/
Phone: 1-800-440-0493 Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Website: Website:
Medicaid: http://health.utah.gov/medicaid https://www.dhs.wisconsin.gov/badgercareplus/p-
CHIP: http://health.utah.gov/chip 10095.htm
Phone: 1-866-435-7414 Phone: 1-800-362-3002
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/ Website:
Phone: 1-800-250-8427 http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
VIRGINIA – Medicaid and CHIP To see if any other states have added a
Medicaid Website: premium assistance program since
http://www.coverva.org/programs_premium_assistance.cf January 31, 2016, or for more
m information on special enrollment rights,
Medicaid Phone: 1-800-432-5924 contact either: U.S. Department of Labor
CHIP Website: or U.S. Department of Health and Human
http://www.coverva.org/programs_premium_assistance.cf Services Employee Benefits Security
m Administration Centers for Medicare &
CHIP Phone: 1-855-242-8282 Medicaid Services
www.dol.gov/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-
2323, Menu Option 4, Ext. 61565
– Medicaid
OMB Control Number 1210-0137 (expires 11/30/2016)
2018
Important Legal Notices – General Notice of

Cobra Continuation Coverage
** Continuation Coverage Rights Under COBRA**
Introduction
You’re getting this notice because you may be eligible for 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 must pay for 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:
2018
Important Legal Notices – General Notice of Cobra Continuation Coverage

(continued)
 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).

(continued)
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. You
must provide this notice to Latoya Belizaire, HR Benefits Administrator via
email at latoya.belizaire@samaritanvillage.org.
How is COBRA continuation coverage provided?
2018
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.
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
(continued)
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,
Medicaid, 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.
If you have questions
2018
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

HR Benefits Administrator Account Manager
Samaritan Daytop Village Inc. OneGroup NY
(718 ) 206-2000 ext. 1324 (718) 897-3903 ext. 15
latoya.belizaire@samaritanvillage.org sclarke@onegroup.com
Important Legal Notices –

Credible Coverage Disclosure Notice
Important Notice from Samaritan Daytop Village Inc

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 with Samaritan
Daytop Village Inc.’s, Inc. 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. Samaritan Daytop Village has determined that the prescription drug coverage
offered by CIGNA Open Access Plus with Health Reimbursement Arrangement is, on
average for all plan participants, expected to pay out as much as standard Medicare
2018
prescription drug coverage pays and 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 15th to December 7th.
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.
2018

Credible Coverage Disclosure Notice (continued)
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 current Samaritan Daytop Village
coverage will not be affected. Medicare eligible individuals, when they become
eligible for Medicare Part D can keep this coverage if they elect part D and this
plan will coordinate with Part D coverage.
If you do decide to join a Medicare drug plan and drop your current Samaritan
Daytop Village coverage, be aware that you and your dependents will not be
able to get this coverage back until next open enrollment.
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 Samaritan
Daytop Village 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…
For further information contact Latoya Belizaire, HR Benefits Administrator at (718)

206-2000 extension 1324, latoya.belizaire@samaritanvillage.org. or call Sarah Clarke
at (877) 877-5155 extension 15.
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 Samaritan Daytop Village
Inc. changes. You also may request a copy of this notice at any time.
2018

Credible Coverage Disclosure Notice (continued)
For More Information About Your Options Under Medicare Prescription

Drug Coverage…
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 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: 11/1/17
Name of Entity/Sender: Samaritan Daytop Village Inc.
Contact--Position/Office: Latoya Belizaire
Address: 138-02 Queens Blvd, Briarwood, NY
11377
Phone Number: (718) 206-2000 ext. 1324
2018
Important Legal Notices - New Health

Insurance Marketplace Coverage Options and
Your Health Coverage
PART A: General Information

When key parts of the health care law took effect in 2014, a new way to buy
health insurance was offered: the Health Insurance Marketplace. To assist you
as you evaluate options for you and your family, this notice provides some
basic information about the new Marketplace.
What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets
your needs and fits your budget. The Marketplace offers "one-stop shopping"
to find and compare private health insurance options. You may also be
eligible for a new kind of tax credit that lowers your monthly premium right
away. Open enrollment for health insurance coverage through the
Marketplace begins in October for coverage starting as early as January 1 of
the following year.
Can I Save Money on my Health Insurance Premiums in the

Marketplace?
You may qualify to save money and lower your monthly premium, but only if
your employer does not offer coverage, or offers coverage that doesn't meet
certain standards. The savings on your premium that you're eligible for
depends on your household income.
Does Employer Health Coverage Afect Eligibility for Premium

Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets
certain standards, you will not be eligible for a tax credit through the
Marketplace and may wish to enroll in your employer's health plan. However,
you may be eligible for a tax credit that lowers your monthly premium, or a
reduction in certain cost-sharing if your employer does not offer coverage to
you at all or does not offer coverage that meets certain standards. If the cost
of a plan from your employer that would cover you (and not any other
members of your family) is more than 9.5% of your household income for the
year, or if the coverage your employer provides does not meet the "minimum
value" standard set by the Affordable Care Act, you may be eligible for a tax
credit.1
Note: If you purchase a health plan through the Marketplace instead of

accepting health coverage offered by your employer, then you may lose the
employer contribution (if any) to the employer-offered coverage. Also, this
employer contribution -as well as your employee contribution to employer-
offered coverage- is often excluded from income for Federal and State income
tax purposes. Your payments for coverage through the Marketplace are made
on an after-tax basis.
2018

Your Health Coverage (continued)
How Can I Get More Information?
The Marketplace can help you evaluate your coverage options, including your
eligibility for coverage through the Marketplace and its cost. Please visit
HealthCare.gov for more information, including an online application for
health insurance coverage and contact information for a Health Insurance
Marketplace in your area.
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.
PART B: Information About Health Coverage Ofered

by Your Employer
This section contains information about any health coverage offered by your
employer. If you decide to complete an application for coverage in the
Marketplace, you will be asked to provide this information. This information is
numbered to correspond to the Marketplace application.
3. Employer name 4. Employer Identification Number (EIN)

Samaritan Daytop 11-2635374
Village Inc.
5. Employer address 6. Employer phone number
138-02 Queens Blvd. (718) 206-2000
7. City 8. State 9. ZIP code
Briarwood NY 11435
10. Who can we contact at this job?
Latoya Belizaire
11. Phone number (if different from 12. Email address
above) Latoya.Belizaire@samaritanvillage.o
same rg
2018

Your Health Coverage (continued)
Here is some basic information about health coverage ofered by this
employer
 As your employer, we offer a health plan to all full time and part time
employees who work 30 hours or more per week.
 This coverage meets the minimum value standard, and the cost of this
coverage to you is intended to be affordable, based on employee
wages.
Although our intent is to provide affordable coverage, you may still be eligible
for a premium discount through the Marketplace. The Marketplace will use
your household income, along with other factors to determine your eligibility.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will

guide you through the process. Listed on the previous page is the employer
information you'll enter when you visit HealthCare.gov to find out if you can
get a tax credit to lower your monthly premiums.
2018
Important Legal Notices – Employee Rights

under the Family and Medical Leave Act
Eligible employees who work for a covered employer can take up to 12 weeks
of unpaid, job-protected leave in a 12-month period for the following reasons:
• The birth of a child or placement of a child for adoption or foster care;
• To bond with a child (leave must be taken within 1 year of the child’s
birth or placement);
• To care for the employee’s spouse, child, or parent who has a
qualifying serious health condition;
• For the employee’s own qualifying serious health condition that makes
the employee unable to perform the employee’s job;
• For qualifying exigencies related to the foreign deployment of a
military member who is the employee’s spouse,
child, or parent.
An eligible employee who is a covered servicemember’s spouse, child,

parent, or next of kin may also take up to 26 weeks of FMLA leave in a single
12-month period to care for the servicemember with a serious injury or
illness.
An employee does not need to use leave in one block. When it is medically
necessary or otherwise permitted, employees may take leave intermittently
or on a reduced schedule.
Employees may choose, or an employer may require, use of accrued paid

leave while taking FMLA leave. If an employee substitutes accrued paid leave
for FMLA leave, the employee must comply with the employer’s normal paid
leave policies.
While employees are on FMLA leave, employers must continue health

insurance coverage as if the employees were not on leave.
Upon return from FMLA leave, most employees must be restored to the same
job or one nearly identical to it with equivalent pay, benefits, and other
employment terms and conditions.
An employer may not interfere with an individual’s FMLA rights or retaliate

against someone for using or trying to use FMLA leave, opposing any practice
made unlawful by the FMLA, or being involved in any proceeding under or
related to the FMLA.
2018
Important Legal Notices – Employee Rights

under the Family and Medical Leave Act
(Continued)
An employee who works for a covered employer must meet three criteria in
order to be eligible for FMLA leave. The employee must:
• Have worked for the employer for at least 12 months;
• Have at least 1,250 hours of service in the 12 months before taking
leave;* and
• Work at a location where the employer has at least 50 employees
within 75 miles of the employee’s worksite.
*Special “hours of service” requirements apply to airline flight crew

employees.
Generally, employees must give 30-days’ advance notice of the need for
FMLA leave. If it is not possible to give 30-days’ notice, an employee must
notify the employer as soon as possible and, generally, follow the employer’s
usual procedures.
Employees do not have to share a medical diagnosis, but must provide

enough information to the employer so it can determine if the leave qualifies
for FMLA protection. Sufficient information could include informing an
employer that the employee is or will be unable to perform his or her job
functions, that a family member cannot perform daily activities, or that
hospitalization or continuing medical treatment is necessary. Employees must
inform the employer if the need for leave is for a reason for which FMLA leave
was previously taken or certified.
Employers can require a certification or periodic recertification supporting the

need for leave. If the employer determines that the certification is
incomplete, it must provide a written notice indicating what additional
information is required.
Once an employer becomes aware that an employee’s need for leave is for a
reason that may qualify under the FMLA, the employer must notify the
employee if he or she is eligible for FMLA leave and, if eligible, must also
provide a notice of rights and responsibilities under the FMLA. If the employee
is not eligible, the employer must provide a reason for ineligibility.
Employers must notify its employees if leave will be designated as FMLA

leave, and if so, how much leave will be designated as FMLA leave.
Employees may file a complaint with the U.S. Department of Labor, Wage and
Hour Division, or may bring a private lawsuit against an employer.
The FMLA does not affect any federal or state law prohibiting discrimination
or supersede any state or local law or collective bargaining agreement that
provides greater family or medical leave rights.

2018 Employee Benefits at A Glance

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2018 Employee Benefits at A Glance

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Benefits at a Glance

Benefit Eligibility Employee

Benefit Type Out of Pocket Expense

Reimbursement $3,500 $4,500 ($9,000 $60,000

Up to $39.93 $72.08 $126.14 $182.34

1) Call Emblem at 1-877-842-3625 $30,001 $49.92 $90.10 $162.17 $234.28

Over $99.84 $180.19 $198.21 $290.44

Benefit Eligibility Employee Cost

Health Employees and Included with Medical

How Does The HRA Work?

Base Plan HRA

High Plan Buy-UP HRA

a. Your Employee ID is your Social Security Number

Samaritan offers two dental 2018 Payroll Deductions (Pre-tax)

Benefit Eligibility Employee Cost

2018 Payroll Deductions (Pre-tax)

Vision $3.93 $7.85 $7.92 $12.65

*Must be legally married. Domestic Partners are not covered.

Cigna Vision PPO

Benefits Questions or Issues?

Benefit Eligibility Employee Contributions

Flexible Full time and part time employees Decided by employee

Now with Choice Debit Card!

Dependent Care FSA How it works

Contact CHOICE by Phone: (888) 278-2555 option 2

You must elect at least 4% to

You must make your election on

1) Log on to the ADP Portal Website

A quick link to get into the Enrollment page is shown

If making changes, select

If adding a dependent for the first time, be prepared to

Latoya Belizaire x 1324

Yelena Agranovskiy x 1233

Important Legal Notices – Special Enrollment & WHCA

To request special enrollment or obtain more information, contact Latoya

Woman’s Health and Cancer Act

Important Legal Notices -

ALABAMA – Medicaid GEORGIA – Medicaid

Important Legal Notices -

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid

MINNESOTA – Medicaid NORTH DAKOTA – Medicaid

Important Legal Notices -

Important Legal Notices – General Notice of

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would

Important Legal Notices – General Notice of Cobra Continuation Coverage

 Your hours of employment are reduced, or

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you

When is COBRA continuation coverage available?

Important Legal Notices – General Notice of Cobra Continuation Coverage

How is COBRA continuation coverage provided?

Second qualifying event extension of 18-month period of continuation

Are there other coverage options besides COBRA Continuation Coverage?

If you have questions

Keep your Plan informed of address changes

Plan contact information

Latoya Belizaire Sarah Clarke

Important Legal Notices –

Important Notice from Samaritan Daytop Village Inc

1. Medicare prescription drug coverage became available in 2006 to everyone with

prescription drug coverage pays and therefore considered Creditable Coverage.