# Plan Year: 2025-2026 > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Aosage_nation%3A12269afb7f092cd2 ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text Welcome to Open Enrollment Plan Year: 2025-2026 Welcome to Open Enrollment Pick the best benefits for you and your family. Osage Nation strives to provide you and your family with a comprehensive and valuable benefits package. We want to make sure you’re getting the most out of our benefits—that’s why we’ve put together this Open Enrollment Guide. Open enrollment is a short period each year when you can make changes to your benefits. This guide will outline all the different benefits offered, so you can identify which benefits are best for you and your family. Elections you make during open enrollment will become effective on October 1, 2025. Employees hired after July 1, 2025, will be effective once you have completed your initial waiting period. If you have questions about any of the benefits mentioned in this guide, please don’t hesitate to reach out to HR. Table of Contents Enrollment Information ........................................................................................................... 3 Health Insurance ...................................................................................................................... 4 Dental Insurance ...................................................................................................................... 9 Vision Insurance ..................................................................................................................... 10 Disability Income Benefits ..................................................................................................... 11 Life Insurance ......................................................................................................................... 12 Voluntary Benefits.................................................................................................................. 13 Flexible Spending Account ..................................................................................................... 16 Employee Assistance Plan ..................................................................................................... 17 Retirement Savings Plan ........................................................................................................ 18 Employer Annual Notices ...................................................................................................... 20 Contact Information............................................................................................................... 32 Welcome to Open Enrollment Welcome to Open Enrollment Who is eligible? If you’re a full-time employee at Osage Nation, you’re eligible to enroll in the benefits outlined in this guide. Fulltime employees are those who work 30 or more hours per week. In addition, the following family members are eligible for medical, dental and vision coverage: • Spouse • Children to age 26 How to enroll? Are you ready to enroll? The first step is to review your current benefits. Did you move recently or get married? Verify all of your personal information and make any necessary changes in the Paycom Benefits Enrollment portal. Once all your information is up to date, it’s time to make your benefit elections. The decisions you make during open enrollment can have a significant impact on your life and finances, so it is important to weigh your options carefully. When to Enroll? Open enrollment begins on August 1, 2025, and runs through August 31, 2025, for existing employees. The benefits you choose during open enrollment will become effective on October 1, 2025. New hires will enroll during your initial waiting period as outlined in your on-boarding process. Changes outside of open enrollment? Unless you experience a life-changing qualifying event, you cannot make changes to your benefits until the next open enrollment period. Qualifying events include things like: • Marriage, divorce or legal separation • Birth or adoption of a child • Change in child’s dependent status • Death of a spouse, child or other qualified dependent • Change in residence • Change in employment status or a change in coverage under another employer-sponsored plan 3 Welcome to Open Enrollment Health Insurance Osage Nation offers coverage through the Blue Cross Native Blue network. This plan is designed to maximize insurance coverage with the goal of keeping you and your covered family members healthy. How to receive Native Blue In-Network Level of Benefits To receive the Native Blue In-Network level of benefits a contracted Native Blue provider must be utilized. To access the doctors and facilities that are in the Native Blue Network please go to the Blue Cross Blue Shield member portal and select the provider search option. www.bcbsok.com The following is a brief summary of medical and pharmacy benefits. Please refer to the Blue Cross Summary Plan Description for a detailed list of covered services. Blue Cross Blue Shield Services Native Blue In-Network Approved Services Out-of-Network Approved Services Physician Visit Copay $0 Deductible, then 50% Deductible (Individual/Family) $0 $1,000 per person Hospitalization Inpatient Outpatient Home Health MRI, CT, Complex Scans $0 Deductible, then 50% Preventive Care $0 Deductible, then 50% Emergency Room Copay $200 copay $200 Copay, Deductible, then 50% Out-of-pocket Maximum (Individual/Family) $0 Unlimited $0 $35 $60 $0 $35 $60 Prescription Drugs - Retail/Mail Order - Generic - Preferred - Non-preferred Mail Order – 90 Days 1x Copay *Please be aware that the use of out-of-network providers and facilities could result in costs that are much higher than the out-of-pocket costs stated in the grid above. 4 Welcome to Open Enrollment Your Cost in 2025-2026 Osage Nation pays most of the employee costs for health insurance but a portion of the cost is the employee responsibility. The per employee per month costs for each level of coverage in listed below. Employee Monthly deductions Employee Only Employee & Spouse Employee & Children Employee & Family $88.98 $572.02 $317.79 $826.25 Health Price Transparency Rule Machine Readable Files Requirements Instructions for Self-Funded Accounts to access the Machine-Readable Files, each account has a unique link to a webpage based on the account’s Employer Identification Number (EIN). This webpage is publicly available without needing a log in. The process for accessing the Out-of-Network (Allowed Amounts) and In-Network Machine-Readable Files will be the same. 1. Link to access: https://bcbsok.com/asomrf?EIN=731509406 Copy the above URL, paste it into the browser. Price Comparison Tool: Blue Cross provides a cost comparison tool that allows you to view the amount each provider or facility charges for standard covered charges. This allows you to be an informed consumer when you select your providers. Access the price comparison through the Blue Access for Members website: www.bcbsok.com. Example of PPO Deductible Being admitted to the hospital and the total charges are $2000. You pay $1000 to cover your annual deductible, then 20% of the $1000 in charges that is left, for a total of $200. $1000 + $200 = $1200 is your responsibility. If you go to the hospital again in the same year and have another $1,000 in charges, you would just be responsible for 20% because you have met your annual deductible, so you would be responsible for $200 for this visit. Final Benefit Determination Actual Benefits will be governed by The Summary Plan Description. Please refer to the Summary Plan Description for clarifications, limitations, exclusions, and covered expenses not addressed in this Schedule of Benefits. Summary of Benefits & Coverage located in Paycom Payroll portal. 5 Welcome to Open Enrollment Wellness & Weight Management Osage Nation is committed to keeping you healthy with the overall theme of removing barriers to care and promoting wellness. Weight management including exercise, healthy eating, and a physician monitored treatment plan will help you obtain a healthy balance now and help prevent future weight related health risks. The wellness plan will cover weight loss medicine prescribed and monitored by your physician. Over the counter or alternative options will not be covered by the plan. Once your treatment plan is established, your physician will coordinate with Blue Cross for approval of weight loss medications based on the Prior Authorization and Step Therapy process designed to encourage safe and effective use of medications. Prior Authorization This program requires your doctor to request pre-approval, or prior authorization, for you to get benefits for medications. • Physician consultation includes BMI levels, chronic illnesses and other risk factors. • Your doctor can find request forms at bcbsok.com/provider. • Treatment decisions are between you and your doctor, but medications must be approved to be covered under the weight management program. Step Therapy The Step Therapy program requires that you use a “preferred” medication before your benefit plan covers a “non-preferred” medication. Step 1: If possible, your doctor should prescribe a preferred medication that is right for your condition. Step 2: If you and your doctor decide that a preferred medication is not right for you, or is not as good in treating your condition, your doctor should submit a step-therapy exception to cover the non-preferred medication. Your doctor can find these request forms at bcbsok.com/provider. Lifestyle Management The key to a successful weight loss program includes creating a lifestyle that will help attain and maintain your ideal weight. Examples are listed below but coordinate with your physician to meet your lifestyle goals. • Physical Activity such as walking • Drinking Water • Member Support through Blue Cross wellness tools Watch for wellness information and tips to a healthier lifestyle information on a regular basis. Notice: This program is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always consult with a qualified and licensed physician or other medical care provider and follow their advice without. 6 Welcome to Open Enrollment Pharmacy Benefit Tools Easily manage your prescriptions online through the Blue Access for Members portal. Save time and money by looking up a prescription, finding a pharmacy in your network or learn about ordering prescriptions for home delivery. Find medicines Find a pharmacy See prescription history Home delivery – 90-Day Supply Skip the lines at the pharmacy You can get medication sent directly to your door with home delivery provided by AllianceRx Walgreens Prime. It's easy to get started with home delivery, sign up today. Blue Cross for Members Tool – Your Online Resource Would you like to know when your medical claims are paid and the payment amounts? Do you need to confirm who in your family is included under your coverage? BAM, the secure member portal from Blue Cross and Blue Shield of Oklahoma (BCBSOK), can help. Get immediate online access to health and wellness information. www.bcbs.com or download the mobile app 7 Welcome to Open Enrollment Blue Cross Virtual Medical Visits – MD Live Care When and Where You Need MD Live, a leading virtual visits leader, lets you visit independently contracted MD Live board-certified doctors when you may need care for non-emergency and pediatric health issues. Reason for a Virtual Medical Visit • • • • Instead of using Emergency Room or Urgent Care Your Doctor is booked While at home, work or on the go Convenience with doctors available 24 hours a day, seven days a week Most common reasons for visiting MD Live • • • • • • Acne Constipation Fever Pink Eye Respiratory Problems Sports Injuries • • • • • • Allergies Cough Headache Rash Sinus Infection Vomiting Connect Interact Computer, smartphone, tablet, or telephone Real time Consultation with a board-certified doctor • • • • • • Mental Health Earaches Insect Bites Cold & Flu Sore Throat Many more… Diagnose Prescriptions sent electronically to a pharmacy of your choice. (When appropriate) Activate MDLIVE now on the Blue App… Get Connected today! To register, you will need to provide your first and last name, date of birth and BCBSOK member ID number 8 Welcome to Open Enrollment Dental Insurance In addition to protecting your smile, dental insurance helps pay for dental care and usually includes regular checkups, cleanings, and X-rays. Several studies suggest that oral diseases, such as periodontitis (gum disease), can affect other areas of your body—including your heart. Receiving regular dental care can protect you and your family from the high cost of dental disease and surgery. The following chart outlines the dental benefits we offer. Type of service Amount Plan Pays Preventive Services Additional periodontal, tooth decay, gum disease and fluoride treatments may be available under the Health through Oral Wellness (HOW) program based on dental evaluation. 100% - Exams, cleanings, X-rays Deductible Applies to basic and major services onl $50 per covered member Basic Services Fillings, root canals, simple extractions - 90% Major Services Oral surgery, bridges, crowns - 60% Annual Maximum $1,500 Orthodontia 50% - Children to 19 years with $1,000 lifetime maximum per child Monthly Payroll Deductions Employee only Employee & Spouse Employee & Child Family $0.00 $38.90 $71.60 $108.68 Register today: www.deltadentalok.org 9 Welcome to Open Enrollment Vision Insurance Osage Nation vision insurance entitles you to specific eye care benefits. Our policy covers routine eye exams and other procedures, and provides specified dollar amounts or discounts for the purchase of eyeglasses and contact lenses. Benefit Description Well Vision Exam Focuses on your eyes and overall wellness Prescription Glasses Frame Lenses Lens Enhancements Contacts (Instead of glasses) Diabetic Eyecare Plus Program Monthly Payroll Deductions In-Network Copay $10 Out of Network Allowance Up to $45 Frequency Every Plan Year $25 $180 Allowance of Frames $200 Allowance of Featured Brands 20% savings over the allowance $70 Costco Frame Allowance Single Vision Lined Bifocal Lined Trifocal Polycarbonate lenses for dependent children Standard, Premium and Custom Progressive lenses Anti-Reflective coating Average savings of 20-25% on other lenses $130 allowance; copay does not apply Contact lens exam Services related to diabetic eye disease, glaucoma and age-related macular degeneration. Ask your VSP doctor for details Employee only Employee & Spouse Employee & child Family Every Plan Year Included with Prescription Copay Included with Prescription Copay Up to $70 Up to $30 Up to $50 Up to $65 $0 $0 Up to $50 Up to $60 Up to $150 $20 Every Plan Year Every Plan Year Every Plan Year As Needed $13.26 $26.11 $24.05 $36.93 VSP Mobile: www.vsp.com for discounts and provider information. Visit the Paycom Portal for information on discount programs or the VSP mobile app 10 Welcome to Open Enrollment Disability Income Benefits Osage Nation provides full-time employees with short-term and long-term disability income benefits. Without disability coverage, you and your family may struggle to get by if you miss work due to an injury or illness. At Osage Nation, we want to do everything we can to protect you and your family. That’s why Osage Nation pays for the full cost of short-term disability. Long-term disability insurance is on a voluntary basis with the employee paying the full cost. In the event that you become disabled from a non-work-related injury or sickness, disability income benefits will provide a partial replacement of lost income. Please note, though, that you are not eligible to receive short-term disability benefits if you are receiving workers’ compensation benefits. Short-term Disability Long-term Disability Benefits Begin 1st day of accident 8th day of illness PTO must be exhausted After 26 Weeks Benefits Payable 26 weeks 5 years Percentage of Income Replaced 60% 60% Maximum Benefit $1,385 $6,000 100% Paid by Osage Employee Paid Based on Annual Salary Calculated by Enrollment Portal Employee Cost 11 Welcome to Open Enrollment Basic Life Insurance Life insurance can help provide for your loved ones if something were to happen to you. Osage Nation pays for the full cost of this benefit—meaning you are not responsible for paying any monthly premiums. Life Insurance Benefit Accidental Death & Dismemberment 1.5 x Annual Salary Minimum Benefit is $50,000 1.5 x Annual Salary Minimum Benefit is $50,000 Age Reduction Schedule: 35% at age 65 50% at age 70 Beneficiary Information: Update Beneficiary in Paycom or contact the Benefits Departments for assistance Employee Monthly Costs 100% Paid by Osage 100% Paid by Osage Voluntary Life Insurance While Osage Nation provides basic life insurance, some employees may want to purchase additional life coverage. With voluntary life insurance, you are responsible for paying the full cost of coverage through biweekly payroll deductions. The chart below outlines the available coverage and monthly costs of purchasing additional coverage. Life Benefit Voluntary Accident Benefit Guarantee Issue Amounts subject to New York Life guidelines Evidence of Insurability Employee Up to 5x annual Salary in $10,000 increments Up to 5x annual Salary in $10,000 increments $160,000 Spouse to age 70 Up to 50% of Employee Election Up to 50% of Employee Election $40,000 Child(ren) $10,000 $10,000 $10,000 Evidence is required for any amounts over the Guarantee Issue for initial enrollees and for any increase in coverage to all existing employees and dependents Portability If you leave employment with Osage Nation request information options from New York Life. Voluntary Life Rates Age Band Age Banded Rates Employee and Spouse 18-29 30-34 35-39 40-44 45-49 Dependent Rate - $10,000 Per pay period deductions Age Reduction Rate per $1,000 $0.103 $0.103 $0.125 $0.180 $0.271 Age Band Rate per Age Band $1,000 50-54 $0.431 75-79 55-59 $0.693 80-84 60-64 $1.062 85-89 65-69 $1.801 90-94 70-74 $3.418 95+ $2.00 per month Calculations for benefit options provided in enrollment portal Rate per $1,000 $6.454 $12.040 $22.196 $36.216 $54.974 35% at age 65 50% at age 70 Not to exceed the $10,000 election band associated with reduction Spouse cannot exceed 50% of employee reduced amount 12 Welcome to Open Enrollment Colonial Life Voluntary Benefits Colonial 24-Hour Accident Plan Cash benefits are paid directly to employees. Helps protect savings and retirement plans 401(k)s from being depleted. Can help pay the mortgage, continue rental payments, or perform needed home repairs for aftercare. See the plan brochure for a complete list of coverage. Benefit Examples Coverage Initial Hospital Confinement $1,000 Daily Hospital Confinement $200 Emergency Room Visit $150 Urgent Care Accident Treatment $75 Ambulance $200 X-Ray $100 Dislocation/Fracture Varies by location and severity See plan documents for a full schedule of benefits and coverage details. Employee Only Employee & Spouse Employee + Child Monthly Payroll Deductions $7.09 $10.64 $13.65 Family $17.34 Colonial Life Critical Illness The benefit is paid upon diagnosis of one of the following conditions and can be purchased in limits of $10,000 or $20,000. Benefits pay directly to employees. BENEFIT EXAMPLES    Heart Attack or Stroke (100%)  Invasive Cancer (100%) End Stage Renal Disease (100%)  Carcinoma in Situ (25%) Coronary Artery Bypass Surgery (25%)  Advanced Parkinson’s Disease (100%) Additional benefits and recurrence benefits vary on payout limits. See plan documents for details. Critical Illness Rates Non-Tobacco Tobacco Rates are based on age and smoker status. Dependent benefit is 50% of the employee benefit amount The enrollment portal will calculate payroll deductions based on benefits elected AGE 18-29 30-39 40-49 50-59 60-74 EE $2.80 $6.10 $11.70 $20.00 $32.90 $10,000 BENEFIT EE+CH EE+SP $2.80 $4.30 $6.10 $8.90 $11.70 $17.50 $20.00 $30.40 $32.90 $49.90 18-29 30-39 40-49 50-59 60-74 $3.70 $9.50 $18.60 $31.90 $52.40 $3.70 $9.50 $18.60 $31.90 $52.40 $5.70 $14.00 $27.70 $48.40 $49.60 FAM $4.30 $8.90 $17.50 $30.40 $49.90 $5.70 $14.00 $27.70 $48.40 $49.60 EE $5.60 $12.20 $23.40 $40.00 $65.80 $20,000 BENEFIT EE+CH EE+SP $5.60 $8.60 $12.20 $17.80 $23.40 $35.00 $40.00 $60.80 $65.80 $99.80 FAM $8.60 $17.80 $35.00 $60.80 $99.80 $7.40 $19.00 $37.20 $63.80 $107.80 $7.40 $19.00 $37.20 $63.80 $107.80 $11.40 $28.00 $55.40 $96.80 $159.20 $11.40 $28.00 $55.40 $96.80 $159.20 13 Welcome to Open Enrollment Colonial Life Voluntary Benefits Colonial Life Hospital Indemnity Cash benefits are paid directly to employees. Helps protect savings and retirement plans 401(k)s from being depleted. Can help pay the mortgage, continue rental payments, or perform needed home repairs for aftercare. See the plan brochure for a complete list of coverage Benefit Examples Initial Hospital Confinement Daily Hospital Confinement Intensive Care Pregnancy Waiting Period Monthly Payroll Deductions Coverage $500 $100 – 10 days max $100 – 10 days max 10 Months See plan documents for a full schedule of benefits and coverage details. Employee Only Employee & Spouse Employee + Child $10.90 $24.39 $15.76 Family $29.26 Colonial Life Rapid Pay Tribal Burial Plan Provides Osage employees and covered dependents access to funds to pay for final expenses within 48 hours. Policy Benefits Coverage Benefit Options Eligible Members Rapid Pay Death Certificate Required Rates Benefit $10,000 AGE 18-39 40-49 50-59 60-64 65+ $10,000 or $20,000 Employee, Spouse and Children to age 26 48-72 hours No – funeral home or hospital verification required Age based rates will calculate in enrollment portal Employee Age $2.40 $2.90 $4.00 $5.20 $9.20 Spouse Age $2.40 $2.90 $4.00 $5.20 $9.20 Child(ren) to age 26 $2.80 per family unit $20,000 18-39 $4.80 $4.80 40-49 $5.80 $5.80 50-59 $8.00 $8.00 60-64 $10.40 $10.40 65+ $18.40 $18.40 Age Reduction applies to 65% at age 70 and 50% at age 75 for employee and spouse coverage. Guarantee Issue for new hires in the initial enrollment period. Evidence of Insurability is required for any member outside of the initial enrollment period. See plan documents for specific details. 14 Welcome to Open Enrollment Norton LifeLock Identity Theft It is more important than ever to protect your identity with the increased exposure to cyber-crime. Identity theft will help you monitor your exposure, • Check your identity health score • Get comprehensive identity and financial monitoring • View and manage real time alerts • Receive high-risk financial transaction alerts • Depend on in-house customer care specialists 24/7 • Reply on $1 million identity expense coverage • Protect you and family members • And much more Refer to detailed benefit guide located on your enrollment portal for coverages and plan restrictions Identity Theft Monthly Rates Family: $11.95 Employee Only: $5.95 Benefit Plan Overview Identity Theft Protection Device Security • • • • • TM LifeLock Identity Alert System Financial protections Lifestyle protection Social protection Protective lock & freeze dashboard Online Privacy • • • Secure VPN Data broker scanning and removal assistance (Privacy Monitor) Solicitation reduction, ad blocker • • • • Norton Device Security Online threat protection Password manager Child online safety tools (Parental Controls) Service & Support • • • Restoration & remediation services Dedicated phone line and email support $3 Million Protection Package 15 Welcome to Open Enrollment Flexible Spending Accounts Paying for health care, dental, hearing, and vision out-of-pocket costs can be stressful. That's why Osage Nation offers an employer-sponsored flexible spending account (FSA). A health care FSA lets you use pre-tax dollars for certain IRS-approved medical care expenses not covered by your insurance plan. For example, cash that you now spend on deductibles, copayments, or other out-of-pocket medical expenses can instead be placed in the health care FSA on a pre-tax basis. What Are the Benefits of a Health Care FSA? There are a variety of different benefits of using a health care FSA, including the following: • It saves you money. Allows you to put aside money tax-free that can be used for qualified medical expenses. • It’s a tax-saver. Since your taxable income is decreased by your contributions, you’ll pay less in taxes. • It is flexible. You can use your FSA funds at any time, even if it’s the beginning of the year. What Is a Dependent Care FSA? Similar to health FSAs, dependent care FSAs allow you to contribute pre-tax dollars to qualified dependent care. The maximum amount you may contribute each year is $5,000 (or $2,500 if married and filing separately). Enrollment Required Complete the FSA Enrollment on Paycom during open enrollment. Health Care Reimbursement Account Annual Contribution Maximum Annual Roll Over Limit Tax Status Covered Expenses IRS defined approved expenses as outlined under the Section 125 Code. Approved expenses are subject to change. $3,300 $660 – excess balance will be forfeited at end of plan year Pre-tax subject to validation Examples include: • Out-of-pocket expenses for Medical, Dental, Vision and Hearing • Eye Surgery or Vision Correction Surgery • Long Term Care • Stop Smoking programs • Weight Loss programs if it is to treat a specific disease Dependent Care Reimbursement Account $5,000 Joint with Spouse $2,500 if married and filing separately None – balance will be forfeited Pre-tax subject to validation Examples include: • Child or Adult dependent care • The cost for an individual to provide care either in or out of your house. • Nursery schools and preschools (excluding kindergarten) • Note: Any amount elected must be used by – September 30, 2025 16 Welcome to Open Enrollment Employee Assistance Plan Benefits You Receive: The Employee Assistance Program is offered to all employees and immediate family members of Osage Nation. It is a completely confidential counseling program that covers issues such as marital and family concerns, depression, substance abuse, grief and loss, financial entanglement, and other personal stressors. To use the EAP, simply contact the Employee Assistance Program toll-free to arrange for a free initial assessment interview. You may be provided brief solution-based counseling, or you may be referred to outside resources for ongoing therapy. Employee Assistance Program Services 918-594-5232  Free Confidential Assessment/Referral/FollowUp Services  24/7 Access for Emergency Situations  Face to Face Assessment Interview  Master-Level Licensed Counselors  Community Based Referrals  Many more… Employee Monthly Costs Free of Charge to employees and their immediate dependents COMPLETELY CONFIDENTIAL 17 Welcome to Open Enrollment Retirement Saving 401(k) Osage Nation offers a 401(k) plan to all full-time employees on the first of the month following 60 days of employment. The reference tool provides you with information to access and manage your plan through BOK Financial Your Retirement Plan Summary Osage Health Systems 401(k) Plan How to register your account on Start Right (If you forget your Username or Password, click on the Forgot Username/ Forgot Password.) Start Right Website startright.bokf.com Start Right Retire Right Download from the App Store or Google Play 1. Visit the startright.bokf.com or download the Start Right app from the App Store or Google Play 2. Don’t have a username? Click Register for online access or New User 3. Enter your social security number and date of birth. 4. Verify you are not a robot and click Register. 5. Create a New User ID and Password (must meet requirements and each item must have a green check mark to continue) 6. Confirm your password and log back in with your new credentials. 7. A verification code will be sent to the phone number your employer has on file for you. 8. Enter the verification code when you receive it and click Submit. Congratulations, you have completed the registration process for online account access! Start Right Interactive Voice Response System You can check your account balance, loan balance or loan payment information at any time by calling 1-800-876-9557. Enter your social security number and your Access code (last 4 digits of your SSN plus the last 2 digits of your birth year) when prompted. How to update your Profile To verify/update your email address, phone number and beneficiaries click your name in the upper right corner of the website or select profile on Start Right mobile. How to add a beneficiary How to enroll in plan To add/update your beneficiaries, log onto the Start Right website or Start Right mobile. You will need the beneficiary’s name, address, social security number, and date of birth. Check out the My RetireRight Planner® to calculate how much to save to reach your goals. Eligibility: You are eligible to participate in the Plan the first day of each month following attainment of age 18 and completion of 60 days Auto Enrollment: Following 60 days of service, you will be automatically enrolled in the plan on the first day of the upcoming month. • • • Automatically withhold 5% of compensation Pre-tax contribution Target Date fund based on your date of birth Enrollment: To set a different contribution rate log onto UKG. To select your own investments and designate your beneficiaries, you can enroll on the Start Right website or Start Right mobile. How to change your contributions The Roth Analyzer can help you decide between Pre-tax or Roth contributions. Contributions limits: You can contribute 1%-100% of your compensation (subject to other deductions from your pay, not to exceed the maximum calendar year dollar amount set by federal regulations): • The 2025 calendar year dollar amount limit is $23,000. • If you are age 50 or older at any time during the calendar year and contribute the maximum dollar amount, you can contribute an additional catch-up contribution of $7,500 Types of contributions: • Pre-tax contributions – money is contributed on a before-tax basis; contributions and their earnings are taxed when withdrawn. • Roth contributions – money is contributed on an after-tax basis; no tax on withdrawals1 1Account must be held for at least five years, employee must be at least 59 1/2, deceased or disabled. 18 Welcome to Open Enrollment Contribution rate changes: To change your contribution, log onto the UKG payroll system. It will become effective as of the next reasonable pay period. Rollover contributions: To roll a prior employer’s plan into this plan, download the rollover form on the Start Right website. In-Plan Roth Transfers: To transfer within the Plan fully vested pre-tax amounts in any contribution source to a corresponding Roth after-tax source download the Roth Transfer form from plan forms. • Minimum transfer: $1,000 • You will be required to pay federal and state (if applicable) income taxes with your individual tax returns on the taxable amount of the transfer Get your free money! How to change your investment selections Employer Matching contributions: • The employer intends to match dollar for dollar up to the first 5% you contribute. You must make salary deferrals to the plan to receive the employer contribution. Vesting schedule: • 0 to 3 years of service: 0% • 3 or more years of service: 100% You may invest in any or all the options below: • Core Investment Funds • Target Date Funds To make changes to your investments, log onto the Start Right website or Start Right mobile. The Determine My Asset Allocation can help you create an investment mix that is right for you. Financial planning services For more detailed financial guidance from a licensed financial consultant, please contact your HR department or Participant Services at 1-800-876-9557. How to take a loan To request or check the status of a loan, log onto the Start Right website. Number of loans: • Maximum of 1 outstanding loan at one time Amount: • Minimum: $1,000 • Maximum: 50% of vested account balance not to exceed $50,000 Terms: • General loan: 5 years Interest rate: • National Prime Rate + 2 Fee: • $100 How to withdraw money You are allowed to take distributions from your account under certain circumstances. For more information log onto the Start Right website. Employee Pre-Tax or Roth Contributions & Employer Contributions (100% Vested): You can take a distribution for the following reasons: • Separation of service • Attain age 59 ½ • Financial Hardship Rollover account: • All or any portion can be withdrawn at any time 19 Welcome to Open Enrollment Employee General Notices: GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS INTRODUCTION This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. Read this notice carefully to help understand your COBRA rights. Keep in mind that 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 when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. This notice does not fully describe COBRA continuation coverage or other rights under the Plan. For additional and more complete 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 does not 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 known as 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 be required to pay for COBRA continuation coverage. Employee If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either of the following qualifying events happens: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. Spouse If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: • 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. In the event your spouse, who is the employee, reduces or terminates your coverage under the Plan in anticipation of a divorce or legal separation that later occurs, the divorce or legal separation may be considered a qualifying event even though the coverage was reduced or terminated before the divorce or separation. Dependent Children Your dependent children (including any child born to or placed for adoption with you during the period of COBRA coverage who is properly enrolled in the Plan and any child of yours who is receiving benefits under the Plan pursuant to a qualified medical child support order) will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens: • The parent-employee dies. • The parent-employees’ 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 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 reductions 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 after the qualifying event occurs. You must provide this notice to the Plan Benefit Manager. The Plan procedures for this notice, including a description of any required information or documentation, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period, you will lose your right to elect COBRA continuation coverage. 20 Welcome to Open Enrollment HOW IS COBRA COVERAGE PROVIDED? Once the Plan Administrator receives timely 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. If COBRA continuation coverage is not elected within the 60-day election period, a qualified beneficiary will lose the right to elect COBRA continuation coverage. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage may last for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended. Also, when the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Disability Extension If you or anyone in your family covered under the Plan is determined by the Social Security Administration 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 total 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 continuation coverage. The Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period and within 18 months after the covered employee’s termination of employment or reduction of hours, there will be no disability extension of COBRA continuation coverage. The affected individual must also notify the Plan Administrator within 30 days of any final determination that the individual is no longer disabled. Second Qualifying Event Extension 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 notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving COBRA continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B or both) or 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. The Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period, there will be no extension of COBRA continuation coverage due to a second qualifying event. ARE THERE OTHER COVERAGE OPTIONS BESIDES COBRA? 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 21 Welcome to Open Enrollment 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. 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 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 Mary Lee Benefits Administrator Osage Nation Human Resources 239 W 12th Street, Pawhuska, OK 74056 Phone: (918) 287-5235 Email: MLee@osagenation-nsn.gov HIPAA PRIVACY NOTICE Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get a copy of health and claims records • You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this. • We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee. Ask us to correct health and claims records • You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this. • We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. • We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not. Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our operations. • We are not required to agree to your request, and we may say “no” if it would affect your care. Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. • We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting us. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. 22 Welcome to Open Enrollment • We will not retaliate against you for filing a complaint. Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: • Share information with your family, close friends, or others involved in payment for your care • Share information in a disaster relief situation If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety. In these cases we never share your information unless you give us written permission: • Marketing purposes • Sale of your information Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. Run our organization • We can use and disclose your information to run our organization and contact you when necessary. • We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans. Example: We use health information about you to develop better services for you. Pay for your health services We can use and disclose your health information as we pay for your health services. Example: We share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. Help with public health and safety issues We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law. Respond to organ and tissue donation requests and work with a medical examiner or funeral director • We can share health information about you with organ procurement organizations. • We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. 23 Welcome to Open Enrollment • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you. • Effective Date of this Notice is October 1, 2025 • Submit requests to Osage Nation privacy officer, Julio Nunez, Director of Human Resources at julio.nunez@osagnation-nsn.gov. HIPAA SPECIAL ENROLLMENT NOTICE This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time. Loss of Other Coverage If you are declining coverage 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). Example: You waived coverage because you were covered under a plan offered by your spouse's employer. Your spouse terminates his employment. If you notify your employer within 30 days of the date coverage ends, you and your eligible dependents may apply for coverage under our health plan. Marriage, Birth or Adoption If you have a new dependent because of a 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 or placement for adoption. Example: When you were hired by us, you were single and chose not to elect health insurance benefits. One year later, you marry. You and your eligible dependents are entitled to enroll in this group health plan. However, you must apply within 30 days from the date of your marriage. If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy. Example: When you were hired by us, your children received health coverage under CHIP, and you did not enroll them in our health plan. Because of changes in your income, your children are no longer eligible for CHIP coverage. You may enroll them in this group health plan if you apply within 60 days of the date of their loss of CHIP coverage. PLAN CONTACT INFORMATION Mary Lee Benefits Administrator Osage Nation Human Resources 239 W 12th Street, Pawhuska, OK 74056 Phone: (918) 287-5235 Email: MLee@osagenation-nsn.gov WOMEN’S HEALTH AND CANCER RIGHTS ACT 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. NEWBORNS AND MOTHERS HEALTH PROTECTION ACT 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). 24 Welcome to Open Enrollment DEPENDENT TO AGE 26 Due to a change in the laws governing your employer’s Group Health Plan, your children generally can be covered until the plan until age 26, regardless of their student or marital status and regardless of whether your home is their principal place of abode or whether you support them. The dependents are eligible for coverage regardless of eligibility on another employer group health plan. MENTAL HEALTH PARITY According to the Mental Health Parity Act of 1996, the group health plan is prohibited from offering benefits that contain annual and/or lifetime dollar maximums for mental health or substance abuse benefits that are more restrictive than limitations imposed on benefits for medical or surgical benefits. However, mental health benefits may be limited to a maximum number of treatment days per year or series per lifetime. GENETIC INFORMATION NONDISCRIMINATION ACT (GINA) The Genetic Information Nondiscrimination Act applies to your Group Health Plan. This law establishes a basic uniform national standard to protect the public from discrimination based on genetic information. HEALTH INSURANCE MARKETPLACE COVERAGE OPTIONS Even if you are offered health coverage through your employment, you may have other coverage options through the Health Insurance Marketplace (“Marketplace”). To assist you as you evaluate options for you and your family, this notice provides some basic information about the Health Insurance Marketplace and health coverage offered through your employment. 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 in your geographic area. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer does not offer coverage, or offers coverage that is not considered affordable and doesn't meet certain minimum value standards (discussed below). The savings that you're eligible for depends on your household income. You may also be eligible for a tax credit that lowers your costs. Does Employment-Based Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that is considered affordable for you and meets certain minimum value standards, you will not be eligible for a tax credit, or advance payment of the tax credit, for your Marketplace coverage and may wish to enroll in your employmentbased health plan. However, you may be eligible for a tax credit, and advance payments of the 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 is considered affordable for you or meet minimum value standards. If your share of the premium cost of all plans offered to you through your employment is more than 9.12%i of your annual household income, or if the coverage through your employment does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit, and advance payment of the credit, if you do not enroll in the employment-based health coverage. For family members of the employee, coverage is considered affordable if the employee’s cost of premiums for the lowest-cost plan that would cover all family members does not exceed 9.12% of the employee’s household income. ii Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered through your employment, then you may lose access to whatever the employer contributes to the employment-based coverage. Also, this employer contribution -as well as your employee contribution to employment-based coverage- is generally excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. In addition, note that if the health coverage offered through your employment does not meet the affordability or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You should consider all of these factors in determining whether to purchase a health plan through the Marketplace. When Can I Enroll in Health Insurance Coverage through the Marketplace? You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period. Open Enrollment varies by state but generally starts November 1 and continues through at least December 15. Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment Period. In general, you qualify for a Special Enrollment Period if you’ve had certain qualifying life events, such as getting married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the qualifying life event to enroll in a Marketplace plan. It is important to make sure that your contact information is up to date to make sure you get any information about changes to your eligibility. To learn more, visit HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325. What about Alternatives to Marketplace Health Insurance Coverage? If you or your family are eligible for coverage in an employment-based health plan (such as an employer-sponsored health plan), you or your family may also be eligible for a Special Enrollment Period to enroll in that health plan in certain circumstances, including if you or your dependents were enrolled in Medicaid or CHIP coverage and lost that coverage. Generally, you have 60 days after the loss of Medicaid or CHIP coverage to enroll in an employment-based health plan. Confirm the deadline with your employer or your employment-based health plan. Alternatively, you can enroll in Medicaid or CHIP coverage at any time by filling out an application through the Marketplace or applying directly through your state Medicaid agency. Visit https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/ for more details. 25 Welcome to Open Enrollment How Can I Get More Information? For more information about your coverage offered through your employment, please check your health plan’s summary plan description or contact human resources. 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. MEDICARE PART D NOTICE Important Notice 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 through your employer 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. Your employer has determined that the prescription drug coverage offered by the employer health plan 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 to December 7. 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 current coverage will be affected. You can keep this coverage if you elect part D and this plan will not coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will only be able to get this coverage back during open enrollment or a special enrollment period. 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 your employer 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. 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 your employer 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 26 Welcome to Open Enrollment PLAN CONTACT INFORMATION Mary Lee Benefits Administrator Osage Nation Human Resources 239 W 12th Street, Pawhuska, OK 74056 Phone: (918) 287-5235 Email: MLee@osagenation-nsn.gov 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 March 17, 2025. Contact your State for more information on eligibility – ALABAMA – Medicaid ALASKA – Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspx ARKANSAS – Medicaid CALIFORNIA – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) FLORIDA – Medicaid Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.mycohibi.com/ HIBI Customer Service: 1-855-692-6442 Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hip p/index.html Phone: 1-877-357-3268 27 Welcome to Open Enrollment GEORGIA – Medicaid INDIANA – Medicaid GA HIPP Website: https://medicaid.georgia.gov/health-insurancepremium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/thirdparty-liability/childrens-health-insurance-program-reauthorization-act2009-chipra Phone: 678-564-1162, Press 2 Health Insurance Premium Payment Program All other Medicaid Website: https://www.in.gov/medicaid/ http://www.in.gov/fssa/dfr/ Family and Social Services Administration Phone: 1-800-403-0864 Member Services Phone: 1-800-457-4584 IOWA – Medicaid and CHIP (Hawki) KANSAS – Medicaid Medicaid Website: Iowa Medicaid | Health & Human Services Medicaid Phone: 1-800-338-8366 Hawki Website: Hawki - Healthy and Well Kids in Iowa | Health & Human Services Hawki Phone: 1-800-257-8563 HIPP Website: Health Insurance Premium Payment (HIPP) | Health & Human Services (iowa.gov) HIPP Phone: 1-888-346-9562 Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-967-4660 KENTUCKY – Medicaid LOUISIANA – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KIHIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kynect.ky.gov Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov/agencies/dms 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 MASSACHUSETTS – Medicaid and CHIP Enrollment Website: https://www.mymaineconnection.gov/benefits/s/?language=en_US Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-977-6740 TTY: Maine relay 711 Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY: 711 Email: masspremassistance@accenture.com MINNESOTA – Medicaid MISSOURI – Medicaid Website: https://mn.gov/dhs/health-care-coverage/ Phone: 1-800-657-3672 Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 MONTANA – Medicaid NEBRASKA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.gov Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178 28 Welcome to Open Enrollment NEVADA – Medicaid NEW HAMPSHIRE – Medicaid Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900 Website: https://www.dhhs.nh.gov/programsservices/medicaid/health-insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 15218 Email: DHHS.ThirdPartyLiabi@dhhs.nh.gov NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Phone: 1-800-356-1561 CHIP Premium Assistance Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 (TTY: 711) Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100 Website: https://www.hhs.nd.gov/healthcare Phone: 1-844-854-4825 OKLAHOMA – Medicaid and CHIP OREGON – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid and CHIP RHODE ISLAND – Medicaid and CHIP Website: https://www.pa.gov/en/services/dhs/apply-for-medicaidhealth-insurance-premium-payment-program-hipp.html Phone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437) Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) SOUTH CAROLINA – Medicaid SOUTH DAKOTA - Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820 Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid UTAH – Medicaid and CHIP Website: Health Insurance Premium Payment (HIPP) Program | Texas Health and Human Services Phone: 1-800-440-0493 Utah’s Premium Partnership for Health Insurance (UPP) Website: https://medicaid.utah.gov/upp/ Email: upp@utah.gov Phone: 1-888-222-2542 Adult Expansion Website: https://medicaid.utah.gov/expansion/ Utah Medicaid Buyout Program Website: https://medicaid.utah.gov/buyout-program/ CHIP Website: https://chip.utah.gov/ VERMONT– Medicaid VIRGINIA – Medicaid and CHIP 29 Welcome to Open Enrollment Website: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427 Website: https://coverva.dmas.virginia.gov/learn/premiumassistance/famis-select Website: https://coverva.dmas.virginia.gov/learn/premiumassistance/health-insurance-premium-payment-hipp-programs Medicaid/CHIP Phone: 1-800-432-5924 WASHINGTON – Medicaid WEST VIRGINIA – Medicaid and CHIP Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 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 WYOMING – Medicaid Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002 Website: https://health.wyo.gov/healthcarefin/medicaid/programsand-eligibility/ Phone: 1-800-251-1269 To see if any other states have added a premium assistance program since March 17, 2025, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565 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. NO SURPRISE BILLING NOTICE Your Rights and Protections Against Surprise M edical Bills When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. You are protected from balance billing for: Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. 30 Welcome to Open Enrollment As of February 2021, the following 18 states had enacted comprehensive Balance Billing Protections: California, Colorado, Connecticut, Florida, Georgia, Illinois, Maine, Maryland, Michigan, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oregon Texas, Virginia, Washington. As of February 2021, the following 15 states had enacted limited Balance-Billing Protections: Arizona, Delaware, Indiana, Iowa, Massachusetts, Minnesota, Mississippi, Missouri, Nebraska, Nevada, North Carolina, Pennsylvania, Rhode Island, Vermont, West Virginia. Generally, those state passed protections apply to fully insured medical plans governed by the specific state and not self-funded medical plans. Check the state insurance commissioner website for details on specific state laws. If your state is not listed, check your state commissioner's website as states may adopt a surprising billing mandate at any time. Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. When balance billing isn’t allowed, you also have the following protections: o You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly. o Your health plan generally must: o Cover emergency services without requiring you to get approval for services in advance (prior authorization). o Cover emergency services by out-of-network providers. o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit. If you believe you’ve been wrongly billed, you may contact the US Department of Health & Human Services at 1-877-696-6775 or your State Insurance Commissioner. DISCLAIMERS This booklet gives you an overview of the primary features of your benefit plans. The plans are administered according to the legal plan documents and insurance contracts. Although we have tried to summarize the provisions of these legal documents clearly and accurately, if any information contained herein conflicts with the legal documents, the legal documents will govern. All benefits are subject to change from time to time and your employer reserves the right to amend or cancel any benefits described in this booklet, with or without notice. The intent of this booklet is to provide you with general information regarding the status of and/or potential concerns related to your current employee benefits environment. It should not be construed as, nor is it intended to provide, legal advice. Laws may be complex and subject to change. This information is based on current interpretation of the law and is not guaranteed. Questions regarding specific issues should be addressed by legal counsel who specializes in this practice area. 31 Welcome to Open Enrollment Contact Information Osage Nation offers you and your eligible family members a comprehensive and valuable benefits program. See below for information on our benefit carriers. You can find all plan documents on the PAYCOM Payroll System. If you have any questions, please contact your Benefits Department. Medical and Prescription Drugs: Flexible Spending (FSA) Customer Service: 800-672-2567 Pharmacy Assistance: 877-546-2779 Web Address: www.bcbsok.com Client Services: 800-339-7493 Web Address: www.britulsa.com Blue Cross Blue Shield of Oklahoma Delta Dental of Oklahoma Benefit Resources, Inc. Vision Service Plan Client Services: 800-522-0188 Web Address: www.DeltaDentalOK.org Customer service 800-877-7195 Web Address: www.vsp.com Life & Disability Insurance Life: Policy# FLX967181 LTD: Policy# LK964929 ADD Policy# OK968689 STD: Policy# SHD962885 Accident -Hospital Indemnity – Critical Illness Burial Expense Web Address: www.ColonialLife.com/access Online Portal for members MD Live – Virtual Visit Call MD Live: 888-676-4204 Web Address: www.MDLIVE.com/BCBSOK Employee Assistance Program Customer Service 800-827-2377 or 918-877-9685 Identity Theft and Cyber Security Web Address: www.Norton.com/benefitplans Phone: 800-607-9174 Osage Nation – Benefits Department Mary Lee Benefits Administrator Osage Nation 239 W. 12th St, Pawhuska, OK 74056 Phone: 918-287-5235 Email: MLee@osagenation-nsn.gov Broker Contact Information: Chimento Insurance Agency Account Executive: Sue Chimento Phone: 918-291-1406 Email: sue@chimentoinsurance.com 32 Welcome to Open Enrollment 33 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Aosage_nation%3A12269afb7f092cd2. Public record. Not legal advice.