2017
Employee Benefits Guide
January 1, 2017 - December 31, 2017
1
This document is an outline of the coverage proposed by the carrier(s). It does not include all of the terms, coverage, exclusions,
limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Your
full Summary Plan Document (SPD) is made available through your Human Resources Department.
The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to your
current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as,
nor is it intended to provide, legal advice. Questions regarding specific coverage issues can be directed to the Benefit Advocates at
Arthur J. Gallagher & Co., [email protected].
2
Table of Contents

Customer Service and Contact Information
1

Eligibility, Enrollment and Useful Benefit Terms
2

Medical Plan Comparison Chart
3

Wellness Incentives
4

Dental Plan Summary
5

Vision Plan Summary
6

Group Life and AD&D
7

Voluntary Life Insurance Benefits & Rates
8

Short-Term and Long-Term Disability Benefits & Rates
9

Gap Plan
10

Long Term Care
11

Aflac - Worksite Products
12 - 13

Employee Assistance Program
14

Flexible Spending Account
15

Payroll Deductions
16

Important Information
17

CHIPRA Notice
18

Medicare D Notice
19 - 20
**If you (and/or your dependents) have Medicare or will become
eligible for Medicare in the next 12 months, a Federal law gives you
more choices about your prescription drug coverage. Please see
pages 19 - 20 for more details.
1
Customer Service and Contact Information
Arthur J. Gallagher & Co. is here to act as a liaison in your dealings with insurance carriers. If you have
questions regarding your coverage or need assistance with claims, let us deal with the insurance
company for you. Please contact anyone at Arthur J. Gallagher & Co. with questions regarding your
benefits package.
Phone:
Email:
844-845-5125
[email protected]
Hours of Operation:
Monday - Friday
7:30 a.m. - 5:30 p.m. CST
Please contact the Benefits Department for information regarding
how to enroll for benefits.
Benefit
Carrier
Group Number/Network
Medical
United Healthcare
Group # 903441
Network: ChoicePlus
866-633-2446
www.myuhc.com
Dental
Assurant
Group # 5469012
Network: Assurant Dental
800-442-7742
www.assurantemployee
benefits.com
Vision
Davis Vision
Group # 503949
800-999-5431
www.davisvision.com
Group Life
and AD&D
Reliance Standard Group # 153132
800-351-7500
www.reliancestandard.com
Voluntary Life
Reliance Standard Group # 153132
800-351-7500
www.reliancestandard.com
Short-Term Disability
Reliance Standard Group # 326577
800-351-7500
www.reliancestandard.com
Long-Term Disability
Reliance Standard Group # 301619
800-351-7500
www.reliancestandard.com
GAP Plan
American Fidelity
N/A
888-485-1347
www.afadvantage.com
Employee Assistance
Program (EAP)
ACI
Company Code: RSLI859
855-775-4357
http://rsli.acieap.com
Flexible Spending
Account (FSA)
TASC
N/A
800-422-4661
www.tasconline.com
Long Term Care
Unum
N/A
800-227-4165
N/A
Accident and Critical
Illness/Cancer
Aflac
N/A
800-433-3036
www.aflac.com
COBRA
Administration
ADP
N/A
800-526-2720
www.benedirect.adp.com
Open Enrollment
ADP
N/A
N/A
https://
workforcenow.adp.com/
public/index.htm
1
Customer Service
Website
Eligibility, Enrollment and Useful Benefit Terms
Eligibility
Co-payment:

Co-payments for office visits and prescription drugs
do not apply toward the deductible but DO apply to the
out-of-pocket payment limit.




New employees are effective the first of the month
following 59 days of full time employment. The first
59 days of employment are considered the
employee’s initial eligibility period.
You are eligible if you are a full-time employee
regularly scheduled to work at least an average of 30
hours a week.
Open enrollment applies to all lines of coverage and
is subject to plan limitations.
The open enrollment period is the only time
employees may enroll in the above listed coverages
without the occurrence of a qualifying event (see
definition below).
Certain benefits are offered during an employee’s
initial eligibility period on a guaranteed-issue basis.
Enrollments/changes requested in certain benefit
plans when an employee is no longer within their
initial eligibility period require evidence of insurability
and enrollment is not guaranteed. Examples of such
plans include: Voluntary Life, STD, LTD, Critical
Illness/Cancer, and Long Term Care.
Calendar Year Deductible and
Out-of-Pocket Maximum:
Expenses incurred toward your annual deductible and
your out-of-pocket maximum are credited on a calendar
year basis. A calendar year is January 1st - December
31st. Your deductible and out-of-pocket maximum will
restart January 1st each year, regardless of the expenses
you incurred in the prior calendar year or when your
annual open enrollment period occurs.
Primary Care Physicians/Specialty
Physician Referrals:
You are NOT required to select a Primary Care Physician
(PCP) or obtain referrals for specialty physicians. For the
best coverage be sure that all providers (doctors, labs,
x-rays, etc.) participate in-network.
Making Enrollment Changes During the
Year:
Dependent Age Limitation:
Your dependent children are eligible for coverage on your
Medical, Dental, Vision, Voluntary Life and Flexible
Spending Account plans until the age of 26 regardless of
their marital, student, or financial dependency status.
In most cases, your benefit elections will remain in effect
for the entire plan year (January 1st - December 31st).
During the annual enrollment period, you have the
opportunity to review your benefit elections and make
changes for the coming year.
In-Network vs. Out-of-Network Benefits:
AMERISAFE’s medical plans offer in-network and out-ofnetwork benefit levels. When a doctor or hospital agrees
to be in the plan’s network, they are contractually bound
not to charge over a specific amount for services covered
by the plan. When you choose an in-network provider,
they will file a claim on your behalf and you are not held
responsible for amounts that the provider may charge in
excess of their contracted rates. Out-of-network expenses
are paid according to ‘Usual and Customary’ charges,
which may leave you with significant out-of-pocket
expenses. For the best benefit available under the plan,
you should utilize in-network providers when possible.
Out-of-network benefit levels can be found on the
Summary of Benefits and Coverage.
You may only make changes to your elections during the
year if you have one of the following status changes:
 Marriage, divorce or legal separation (if your state
recognizes legal separation);
 Gain or loss of an eligible dependent for reasons such
as birth, adoption, court order, disability, death;
reaching the dependent child age limit; or
 Significant changes in employment or employersponsored benefit coverage that affect you or your
spouse’s benefit eligibility.
 Your benefit change must be consistent with your
change in family status.
IRS regulations require that for enrollment due to the
qualifying events above, change forms must be
submitted within 30 days of that qualifying event.
Contact your Benefits Department for information on
completing these forms.
2
Medical Plan Comparison Chart
PPO Plan
In-Network Benefits
PPO Plan
Out-Of-Network Benefits
Annual Deductible
Co-pays do not accumulate
$1,500 Individual
$3,000 Family
$3,000 Individual
$6,000 Family
Annual Out-of-pocket Maximum
Includes deductible, co-insurance and co-pays
$3,500 Individual
$7,000 Family
$7,000 Individual
$14,000 Family
10%
30%
Hospital Services - Inpatient
10% after deductible
30% after deductible
Emergency Room Treatment
(Emergency Situation)
$350 co-pay
$350 co-pay
Urgent Care Center Services
Additional services/supplies may incur additional fees
$75 co-pay
30% after deductible
$20 co-pay
$20 co-pay
30% after deductible
30% after deductible
Paid at 100%
Not Covered
10% after deductible
30% after deductible
Paid at 100%
30% after deductible
10% after deductible
30% after deductible
$10 co-pay
$25 co-pay
$50 co-pay
The applicable co-pay
below plus the difference
in cost.
$10 co-pay
$25 co-pay
$50 co-pay
Benefit
Co-insurance (amount you pay after deductible)
Physician Visits
Primary Care Physician
Specialist
Preventive Care (Office Visit)
Physician’s Services
Preventive Testing
Outpatient Surgery
Diagnostic Lab and X-Ray - Outpatient
Major Diagnostic
(CT, PET, MRI, MRA and Nuclear Medicine)
Prescription Drug Program1
(30 day supply)
Tier 1
Tier 2
Tier 3
1
Prescription Drug Program - Continued
Mandatory Mail Order is required for Specialty Medications
Mandatory Mail Order for Certain Maintenance Medications - Unless Opt Out is Selected
Step Therapy and/or Prior Authorization May Be Required - More information on the Benefits Intranet
Please review your plan document for an exact description of the services and supplies that are covered, those
which are excluded or limited, and other terms and conditions of coverage.
3
Wellness Incentives
Wellness Incentives
One of the main goals of the AMERISAFE benefits program is to keep employees and their families healthy.
To show our dedication to your health, AMERISAFE offers the following wellness incentives:
Gym Membership Reimbursement - All Eligible Employees
A reimbursement of up to $25.00 per month will be provided to employees actively enrolled in a gym
membership. To qualify for this reimbursement you must provide documentation showing your monthly cost
as well as the name of the gym you are attending to the Benefits Department. This reimbursement will be
reflected on the final paycheck of each month. Recertification of membership status is required every July
and January. Simply provide proof of your July and January payments to the Benefits Department to
continue receiving the incentive. Employees who cancel their membership between recertification periods
are required to notify Rebekah Fontenot in the Benefits Department immediately.
Time Off For Wellness Exam - All Eligible Employees
Even if you are not enrolled in the AMERISAFE Medical plan, you are eligible for up to four hours of paid
time off once annually to obtain a Routine Wellness examination. To obtain this benefit, your health care
provider must complete the Wellness Exam Certification Form, which is located on the Benefits intranet.
Your form must be returned to the Benefits Department.
Employees Enrolled in the AMERISAFE Medical Plan
A reimbursement of $115.00 will be provided to employees enrolled in the AMERISAFE Medical Plan who
have a Routine Wellness examination between November 1, 2016 and November 1, 2017. The $115
reimbursement will be reflected on eligible employees’ mid-December paychecks and is subject to all
applicable taxes. To obtain this benefit, your health care provider must complete the Wellness Exam
Certification Form, which is located on the Benefits intranet. Your form must be returned to the
Benefits Department by November 10, 2017 in order to receive this incentive.
4
Dental Plan Summary
Basic Plan
Enhanced Plan
Type I - Preventive Services *
Cleanings, exams, x-rays
(Note: Preventive services do not apply towards your
annual benefit maximum.)
20% - no deductible
20% - no deductible
Type II - Basic Services
Fillings, root canals, non-surgical periodontal, oral
surgery, extractions,
20% after deductible
20% after deductible
Type III - Major Services
Crowns (5-year replacement), inlays/onlays, bridges,
dentures, repairs, surgical periodontal care
50% after deductible
50% after deductible
Annual Deductible
$75 Individual
$225 Family
$75 Individual
$225 Family
Annual Maximum
$1,000
$2,000
50% to $1,000 lifetime
maximum per person.
50% to $1,000 lifetime
maximum per person.
Benefit
Orthodontia
* Preventive Services apply toward the calendar year maximum.
While there is a network of providers you can utilize, benefit percentages are the same regardless of whether
you visit an in-network or out-of-network provider. Utilizing an in-network provider will result in a lower patient
responsibility overall. Please review your plan document for an exact description of the services and supplies
that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Out-of-Network benefits are subject to Reasonable and Customary charges and you may be balance-billed if
your dentist charges above this amount.
5
Vision Plan Summary
Benefit
In-Network
Eye Exam
$10 co-pay
Frames/Lenses
Single Vision
$10 co-pay
Bifocal Lenses
$10 co-pay
Trifocal Lenses
$10 co-pay
Frames
Covered in full frames
Frame Allowance
Contacts - in lieu of glasses
Davis Vision Collection
Standard, Soft Contacts
Contact Lens Evaluation &
Fitting
Any Fashion or Designer level frame from Davis Vision’s Collection
$130 allowance toward any frame plus 20% off balance
No charge for one year’s supply
No co-pay, $130 allowance
$10 co-pay (in addition to Exam co-pay)
Exam Frequency
Every calendar year
Lens Frequency
Every calendar year
Frames Frequency
Every other calendar year
Please review your plan document for an exact description of the services and supplies that are covered,
those which are excluded or limited, and other terms and conditions of coverage.
6
Basic Term Life Insurance and AD&D
Group Life and AD&D Benefits
Benefit
$50,000
Guarantee Issue Amount
$50,000
Accidental Death & Dismemberment
$50,000
50% at age 70
Benefits end at retirement
Age Reduction Schedule
7
Voluntary Life Insurance Benefits & Rates
Voluntary Life Benefits
Employee Life Amount
$500,000 ($10,000 increments)
Employee Guarantee Issue Amount
$200,000 (under age 70)
Spouse Life Amount
$250,000 ($5,000 increments)
Spouse Guarantee Issue Amount
$50,000 if under age 70
14 days to 6 months - $500
6 months to age 26 - $10,000
Child Life Amount
Age Reduction Schedule
50% at age 70
Portability
Included
Newly-eligible: Employees and dependents may elect coverage up to the Guaranteed Issue amount
without answering any medical questions.
During annual open enrollment: Employees currently enrolled in the Voluntary Life Plan may
request up to $40,000 in additional coverage for themselves, in $10,000 increments, without
providing Evidence of Insurability (EOI). Employees who currently have their spouse enrolled in
this plan may request up to $20,000 in additional coverage, in $5,000 increments, without providing
EOI for their spouse.
Please note that dependents in a state of limited ability are not eligible for increases without
completion of an Evidence of Insurability form and approval by RSL.
Employee and Spouse
(rate per $1,000—Spouse based on employee age)
Age Rated Premiums
Life Rate: Up to 30
$0.07
30 - 34
$0.08
35 - 39
$0.11
40 - 44
$0.16
45 - 49
$0.27
50 - 54
$0.47
55 - 59
$0.73
60 - 64
$0.95
65 - 69
$1.65
70 - 74
$2.65
75 - 79
$4.24
Child Life Rate (per $1,000)
$0.20
**For example: A 36-year-old employee wants $100,000 of coverage**
$100,000 ÷ $1,000 =
Elected
Benefit
Amount
100
x
$0.11 =
Rate
Above
$11.00
Your
Monthly
Cost
To qualify for the Guarantee Issue Benefits of the plan as outlined above, employees and spouses must be under age
70. Employees must be actively at work and dependents may not be in a period of
limited activity.
8
Short and Long-Term Disability
Short-Term Disability Benefits1
Weekly Benefit
60% of weekly income
Maximum Weekly Benefit
$1,250
Elimination Period
Accident Benefit Begins
Illness Benefit Begins
15th day
15th day
Benefit Duration
Up to 11 weeks
RATE PER $10 OF BENEFIT=$.30
**Example below is for an employee who earns $40,000 per year.**
To calculate your weekly salary
$40,000
÷ 52 =
$769.23
Annual Salary
Multiply your weekly salary by the 60% benefit, divide by the $10 benefit rate, then
multiply by $.31. This is your monthly rate.
$769.23
x 60% ÷ $10
$0.31
x
Weekly
Salary
Rate
Above
=
$14.31
Your Monthly
Rate
1
Employees that have previously declined enrollment in the Short Term Disability Plan must submit
Evidence of Insurability and Enrollment is not guaranteed.
Long-Term Disability Benefits1
Monthly Benefit
60% of income
Maximum Monthly Benefit
$5,000
Elimination Period
90 days
Maximum Benefit Duration
Social Security Normal Retirement Age
Own Occupation Limitation
24 months
Mental/Nervous Limitation
24 months
Substance Abuse Limitation
24 months
Benefits Integration
Full Family Direct
Pre-existing Limitation
3 / 12
Survivor Benefit
3 months
RATE PER $100 OF COVERED PAYROLL = $.49
**Example below is for a 36 year-old employee who earns $30,000 per year**
Step 1:
Divide annual salary by 12 (to get your monthly salary)
$30,000 / 12 = $2,500.00
Step 2:
Divide your monthly salary by 100
$2,500 / 100 = $25
Step 3:
Multiply step 2 by $.49 to determine monthly premium
1
25 X .49 = $12.25
Employees that have previously declined enrollment in the Long Term Disability Plan must submit
Evidence of Insurability and enrollment is not guaranteed.
9
GAP Plan - American Fidelity
Please see the Important Policy Provisions in the GAP Brochure located on the Intranet,
under the Benefits Department tab.
10
Long-Term Care
UNUM Long-Term Care Benefit and Premium Information can be located on the Intranet,
under the Benefits Department tab..
11
Aflac Information
12
Aflac Information
For more information on Aflac products,
please refer to the plan documents located on the
AMERISAFE intranet.
13
Employee Assistance Program (EAP)
14
Flexible Spending Account (FSA)
FSA annual election not to exceed $2,500
Dependent Care annual election not to exceed $5,000
15
Payroll Deductions
PPO Medical Plan
Monthly Employee Cost
Monthly AMERISAFE Cost
Annual AMERISAFE Cost
Employee Only:
$115.00
$538.20
$6,458.40
Employee + Spouse:
$402.00
$1,041.58
$12,498.96
Employee + Child(ren):
$319.00
$804.55
$9,654.60
Employee + Family:
$498.00
$1,403.08
$16,836.96
Employee Only:
$13.00
$8.87
$106.44
Employee + 1:
$29.00
$14.78
$177.36
Employee + 2 or more:
$37.00
$35.17
$422.04
Basic Dental Plan (with Medical Coverage)
Enhanced Dental Plan (with Medical Coverage)
Employee Only:
$16.00
$9.16
$109.92
Employee + 1:
$36.00
$14.37
$172.44
Employee + 2 or more:
$48.00
$35.00
$420.00
Basic Dental Plan (without Medical Coverage)
Employee Only:
$0.00
$21.87
$262.44
Employee + 1:
$0.00
$43.78
$525.36
Employee + 2 or more:
$0.00
$72.17
$866.04
Enhanced Dental Plan (without Medical Coverage)
Employee Only:
$2.00
$23.16
$277.92
Employee + 1:
$4.00
$46.37
$556.44
Employee + 2 or more:
$7.00
$76.00
$912.00
Employee Only:
$8.82
$0.00
$0.00
Employee + Spouse:
$15.89
$0.00
$0.00
Employee + Child(ren):
$16.75
$0.00
$0.00
Employee + Family:
$26.47
$0.00
$0.00
Under age 55
Ages 55-59
Ages 60+
Employee Only:
$17.50
$26.30
$43.80
Employee + Spouse:
$31.50
$47.30
$78.80
Employee + Child(ren):
$28.00
$36.80
$54.30
Employee + Family:
$42.00
$57.80
$89.30
Vision Plan
Voluntary GAP Plan (Monthly Employee Cost)
Voluntary Life
See Rate Chart on Page 8
Short & Long-Term Disability
See Rate Chart on Page 9
Long Term Care
See Rate Chart on Intranet
16
Important Information
This book highlights some of the main features of
your benefit programs, but does not include all plan
rules, features, limitations or exclusions. The terms of
your benefit plans are governed by legal documents,
including insurance contracts. Should there be any
inconsistencies between this book and the legal
plan documents, the plan documents are the final
authority. AMERISAFE reserves the right to change or
discontinue its benefit plans at any time.
The Women’s Health and Cancer Rights
Act
Do you know that your plan, as required by the Women’s
Health and Cancer Rights Act of 1998, provides benefits
for mastectomy-related services including all stages of
reconstruction and surgery to achieve symmetry between
the breasts, prostheses, and complications resulting from
a mastectomy, including lymphedema? Contact the
Human Resources Department for more information.
HIPAA Privacy 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.
HIPAA requires AMERISAFE to notify you that a privacy
notice is available upon request. Please contact Human
Resources if you have any questions.
Summary of Material Modification/
Reduction
This Summary of Material Modification (SMM)
describes changes to the AMERISAFE plans and
supplements the Summary Plan Description (SPD) for
the plan. The effective date of each of these changes
is January 1st, 2017. You should read this SMM very
carefully and retain this document with your copy of
the SPD for future reference.
These benefits will be provided subject to the same
deductibles and co-insurance applicable to other medical
and surgical benefits provided under the AMERISAFE
Health Plan. Please see the Medical Benefit Plan for
specific details.
17
18
Medicare D Notice
Important Notice from AMERISAFE, 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 AMERISAFE, 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.
AMERISAFE, Inc. has determined that the prescription drug coverage offered by the AMERISAFE, Inc.
medical 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 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.
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 AMERISAFE, Inc. coverage will not be affected. Your current
coverage pays for other health expenses in addition to prescription drug. Please see the Medical Benefit Plan in this
book for specific details about the prescription drug coverage.
If you enroll in a Medicare prescription drug plan, you and your eligible dependents will be eligible to receive all of your
current health and prescription drug benefits and your coverage will coordinate with Medicare.
If you do decide to join a Medicare drug plan and drop your current AMERISAFE, Inc. coverage, be aware that you
and your dependents may not be able to get this coverage back.
CMS Form 10182-CC
Updated April 1, 2011
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
19
Medicare D Notice
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 AMERISAFE, Inc. and don’t join a Medicare
drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to
join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go
up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that
coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at
least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty)
as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October
to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You will 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 AMERISAFE, Inc. changes.
You also may request a copy of this notice at any time.
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You”
handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly
by Medicare drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available.
For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at
1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this creditable coverage notice. If you decide to join one of the Medicare drug plans, you
may be required to provide a copy of this notice when you join to show whether or not you have maintained
creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
January 2017
AMERISAFE, Inc.
Benefits Department
2301 Highway 190 West
DeRidder, LA 70634
(337) 460-3675
CMS Form 10182-CC
Updated April 1, 2011
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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