Premium Assistance Under Medicaid and the Children s Health Insurance Program (CHIP)

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1 Required Notices Federal regulations require employers to provide employees with specific information (legal notices) on an annual basis concerning their rights and responsibilities under a benefits program. These notices cover a variety of topics and may not apply to every employee. Please review the following information carefully and keep it for future reference. 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 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 KIDS NOW or 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 or call 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 August 10, Contact your State for more information on eligibility

2 ALABAMA Medicaid Phone: ARKANSAS Medicaid Phone: MyARHIPP ( ) FLORIDA Medicaid Phone: INDIANA Medicaid Healthy Indiana Plan for low-income adults Phone: All other Medicaid Phone KANSAS Medicaid Phone: LOUISIANA Medicaid Phone: MASSACHUSETTS Medicaid and CHIP ALASKA Medicaid The AK Health Insurance Premium Payment Program Phone: Medicaid Eligibility: COLORADO Health First Colorado (Colorado s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Health First Colorado Member Contact Center: / State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: / State Relay 711 GEORGIA Medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: IOWA Medicaid Phone: KENTUCKY Medicaid Phone: MAINE Medicaid Phone: TTY: Maine relay 711 MINNESOTA Medicaid

3 masshealth/ Phone: MISSOURI Medicaid pages/hipp.htm Phone: NEBRASKA Medicaid Phone: (855) Lincoln: (402) Omaha: (402) NEW HAMPSHIRE Medicaid Phone: NEW YORK Medicaid Phone: NORTH DAKOTA Medicaid Phone: OREGON Medicaid Phone: RHODE ISLAND Medicaid Phone: SOUTH DAKOTA - Medicaid Phone: health-care/health-care-programs/programs-andservices/medical-assistance.jsp Phone: MONTANA Medicaid Phone: NEVADA Medicaid Medicaid Medicaid Phone: NEW JERSEY Medicaid and CHIP Medicaid dmahs/clients/medicaid/ Medicaid Phone: CHIP CHIP Phone: NORTH CAROLINA Medicaid Phone: OKLAHOMA Medicaid and CHIP Phone: PENNSYLVANIA Medicaid nsurancepremiumpaymenthippprogram/index.htm Phone: SOUTH CAROLINA Medicaid Phone: TEXAS Medicaid Phone:

4 UTAH Medicaid and CHIP Medicaid CHIP Phone: VIRGINIA Medicaid and CHIP Medicaid premium_assistance.cfm Medicaid Phone: CHIP premium_assistance.cfm CHIP Phone: WEST VIRGINIA Medicaid Toll-free phone: MyWVHIPP ( ) VERMONT Medicaid Phone: WASHINGTON Medicaid Phone: ext WISCONSIN Medicaid and CHIP p1/p10095.pdf Phone: WYOMING Medicaid Phone: To see if any other states have added a premium assistance program since August 10, 2017, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Menu Option 4, Ext

5 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L ) (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 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 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 or ebsa.opr@dol.gov and reference the OMB Control Number OMB Control Number (expires 12/31/2019) Special Enrollment Rights Under HIPAA If you decline enrollment for yourself or a dependent because of other health insurance or group coverage, and if you lose eligibility for that coverage or the employer stops contributing toward the other coverage, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 31 days after the other coverage ends (or the other employer ceases their contribution.) In addition, if you have one of the family status changes shown below, you may be able to enroll yourself and your other dependents. However, you must request enrollment within 31 days after the event by contacting Human Resources. You must call Human Resources directly, not the insurance company. Marriage, divorce or legal separation Birth or adoption of a child (do not wait until you have the birth certificate or Social Security number) A dependent dies or is no longer eligible You or your dependent gains or loses benefit coverage due to a change in employment or employer plan COBRA coverage (provided by an employer other than Dresser) expires You, your spouse, or dependent gains or loses eligibility for Medicare or Medicaid A judgment, decree or court order requires that you provide coverage for a dependent. See your Benefits Handbook for more information.

6 Women s Health and Cancer Rights Act (WHCRA) On October 21, 1998, the federal government passed the Women s Health and Cancer Rights Act. As part of our plan s compliance with this Act, we are required to provide you with this annual notice outlining the coverage that this law requires our plan to provide. Our group health plans all provide coverage for medically-necessary mastectomies. This coverage includes procedures to reconstruct the breast, on which the mastectomy was performed, as well as the cost of necessary prostheses (implants, special bras, etc.) and treatment of any physical complications resulting from any stage of the mastectomy. However, as a result of this federal law, the plan also provides coverage for surgery and reconstruction of the other breast to achieve a symmetrical appearance and any complications that result from that surgery. The following benefits must be provided if benefits are provided for a mastectomy: 1. Coverage for reconstruction of the breast on which the mastectomy is performed 2. Coverage for surgery and reconstruction of the other breast to produce a symmetrical appearance with the breast on which the mastectomy is performed. 3. Coverage for prostheses and physical complications resulting from any stage of the mastectomy, including lymphedemas. These benefits are subject to the same deductibles, copays and coinsurance that apply to mastectomy benefits Important Notice from i+icon 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 [Insert Name of Entity] 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. I+icon has determined that the prescription drug coverage offered by the CIGNA 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 I+icon coverage will be affected. If you do decide to join a Medicare drug plan and drop your current I+icon coverage, be aware that you and your dependents will not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with [Insert Name of Entity] 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.

7 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 call Human Resources at 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 I+icon 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 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 MEDICARE ( ). TTY users should call 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 or call them at (TTY ). 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).

8 HIPAA TRIENNIAL NOTICE Your health insurance coverage with Fidelity Security Life Insurance Company complies with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requirements. These requirements are described in the Notice of Privacy Practices ("Notice") that was previously provided to you with your insurance policy or certificate. A copy of the Notice is maintained on our Company website at If you would like a paper copy of the Notice, please contact your employer. Or, you may contact our Customer Service Department by phone at (800) , Monday through Friday 8:30 a.m. to 5:00 p.m., CST, or in writing at: Fidelity Security Life Insurance Company HIPAA Customer Service 3130 Broadway Kansas City, MO HIPAA TRIENNIAL NOTICE - EMPLOYEE

9 FACTS WHAT DOES Fidelity Security Life Insurance Company, Fidelity Security Life Insurance Company of New York (NY Only) and Affiliates DO WITH YOUR PERSONAL INFORMATION? Why? What? Financial companies choose how they share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. The types of personal information we collect and share depend on the product or service you have with us. This information can include: Social Security number and transaction history medical information and insurance claim information assets and checking account information When you are no longer our customer, we continue to share your information as described in this notice. How? All financial companies need to share customers personal information to run their everyday business. In the section below, we list the reasons financial companies can share their customers personal information; the reasons Fidelity Security Life Insurance Company and Affiliates choose to share; and whether you can limit this sharing. Reasons we can share your personal information Does Fidelity Security Life share? Can you limit this sharing? For our everyday business purposes such as to process your transactions, maintain your account(s), respond to court orders and legal investigations, or report to credit bureaus For our marketing purposes to offer our products and services to you Yes Yes No No For joint marketing with other financial companies Yes No For our affiliates everyday business purposes information about your transactions and experiences For our affiliates everyday business purposes information about your creditworthiness Yes No No We don t share For our affiliates to market to you No We don t share For nonaffiliates to market to you No We don t share Questions? Call or go to or

10 Who we are Who is providing this notice? Fidelity Security Life Insurance Company and Affiliates including our Administrative, Insurance and Financial Service Providers. What we do How does Fidelity Security Life Insurance Company and Affiliates protect my personal information? How does Fidelity Security Life Insurance Company and Affiliates collect my personal information? Why can t I limit all sharing? To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured files and buildings. These physical, electronic and procedural safeguards were created to protect your information. We also limit employee access as appropriate. We collect your personal information, for example, when you apply for insurance or pay insurance premiums file an insurance claim or give us your contact information show your driver s license We also collect your personal information from others, such as credit bureaus, affiliates, or other companies. Federal law gives you the right to limit only sharing for affiliates everyday business purposes information about your creditworthiness affiliates from using your information to market to you sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. Definitions Affiliates Nonaffiliates Joint marketing Companies related by common ownership or control. They can be financial and nonfinancial companies. Our affiliates include Fidelity Security Life Insurance Company of New York, Forrest T. Jones & Company, Inc., Forrest T. Jones Consulting Company and National Pension & Group Consultants, Inc. Companies not related by common ownership or control. They can be financial and nonfinancial companies. Fidelity Security Life Insurance Company does not share with nonaffiliates so they can market to you. A formal agreement between nonaffiliated financial companies that together market financial products or services to you. Our joint marketing partners include insurance agencies, broker dealers and investment advisor firms.

11 About This Guide This benefit summary provides selected highlights of the i+iconusa employee benefits program. It is not a legal document and shall not be construed as a guarantee of benefits nor of continued employment at the Company. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of such policies, contracts and plan documents shall be governed by the terms of such policies, contracts and plan documents. i+iconusa reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The authority to make such changes rests with the Plan Administrator.