13873 Park Center Road, Suite 300N Herndon, VA Telephone: Fax: Non-SCA Edition. w w w. a k i m a. c o m.

Transcription

1 October Park Center Road, Suite 300N Herndon, VA Telephone: Fax: w w w. a k i m a. c o m Non-SCA Edition

2 Table of Contents Disclaimer Information What You Should Know...1 Premera Medical and Prescription Drug Plans...5 Benefits Enrollment... Dental and Vision Plan Summaries...6 Be Sure To Verify and Update... Benefit Rates... Important To Note... Prudential and Other Insurance Coverages...7 If You Do Not Take Action... Basic Life Insurance And AD&D... How To Enroll...2 Voluntary Life Insurance For You... Log On And Sign In... Voluntary Dependent Life Insurance For Your Spouse.. Make Your Choices And Enroll... Voluntary Life Rate Table for Employee And Spouse... Confirm Your Elections And Enrollment... Voluntary Dependent Life Insurance For Your Enrolling By Telephone... Child(ren)... Enrolling In 401(k) Benefits... Business Travel Accident (BTA)... Important Information...3 Contact Information...8 Health Advocate Services... Disclosure Information...9 About This Guide... Plan Summaries... Misrepresentation... Important!... Your Choices...4 Health Plans... Waiving Medical Coverage... Life and Disability Plans... Fraud Statement: All enrollees certify that any persons on their applications for coverage are their dependents, as defined under the Plan. They agree that falsification of any statement in their application may bar the right to coverage under the Plan. They certify that the information they have provided is complete, accurate and true. Enrollees must notify their employer when their child(ren), spouse or domestic partner NO longer meet the eligibility requirements as defined under the plan. If a child(ren), spouse or domestic partner no longer meet the plan s definition of eligible they will be no longer eligible for the benefits. If inaccurate or false information is furnished on the application and/or failure to notify the employer that dependent(s) are longer eligible the result could be termination of coverage, non-payment of benefits, recovery of ineligible benefit payments, termination of employment and/or legal action. Patient Protection: Akima s Medical Plan generally does not require the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Anthem Blue Cross Blue Shield of Missouri at You do not need prior authorization from Anthem Blue Cross Blue Shield or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Anthem Blue Cross Blue Shield of Missouri at Summary of Material Modification (SMM): Please note that this benefit summary is intended to serve as a Summary of Material Modification (SMM), as described in the Employee Retirement Income Security Act (ERISA). Please keep this information with your Certificate of Coverage provided by the carrier. Pre-Existing Condition: The Akima Health Plan has no pre-existing condition clause. Special Enrollment: HIPAA (Health Insurance Portability and Accountability Act) requires that you are made aware regarding special enrollment period. If you acquire a new dependent or decline coverage under the plan while other coverage is in effect and later you lose that coverage for qualifying reasons you have the right to enroll in this plan. Loss of Coverage for Medicaid or a State Children s Health Insurance Program (SCHIP): If you decline to enroll yourself or an eligible dependent (including a spouse) while Medicaid coverage or coverage under a state children s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. You must request to be enrolled within 60 days after you or your dependents coverage ends under Medicaid or the state children s health insurance program. New Dependent by Birth, Adoption or Marriage: If you have a new dependent you may be able to enroll yourself and your new dependents on to this plan. You must request enrollment within 31 days after the birth, adoption or marriage. Eligibility for Medicaid or State Children s Health Insurance Program (SCHIP): If you or your dependents become eligible for a state premium assistance subsidy through state s children s health insurance program or Medicaid you may be able to enroll yourself and your dependents in this plan. You must request enrollment within 60 days after you or your dependents determination of eligibility for such assistance is approved. Women s Health and Cancer Rights Act of 1998 Annual Notice: Under Federal law, group health plans and health insurance issuers providing benefits for a mastectomy must also provide, in connection with the mastectomy for which the participant or beneficiary is receiving benefits, coverage 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 physical complications of mastectomy, include lymph edemas in a manner determined in consultation between the attending physician and the patient. These benefits may be subject to annual deductibles and coinsurance provisions that are appropriate and consistent with other benefits under the coverage. Newborns and Mothers Health Protection Act: Under Federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not 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 delivery. However, the plan or issuer may pay for a shorter stay if the attending physician, nurse midwife or physician assistant, after consultation with the mother, discharges the mother or newborn earlier. Plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour for normal delivery, or 96-hour stay for Cesarean delivery, is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not require that a physician or health care provider obtain authorization for prescribing a length of stay of up to 48-hour for normal delivery, or 96-hour stay for Cesarean delivery. However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain pre-certification. For information on pre-certification, contact your plan administrator. For coverage that is insured, if your state has a law that meets certain criteria, state law applies to your coverage rather than the Newborns Act. A list of states in which the federal Newborns Act requirements apply as of July 1, 1998 can be found in the Newborns Act Questions and Answers: Recent Changes in Health Care Law. Page 9

3 What You Should Know Benefits Enrollment Akima is committed to providing comprehensive and competitive benefits to you and your family. If you are a regular full-time or part-time employee working 30 hours or more, you are eligible to enroll in Akima s Benefits Plan and must enroll within 30 days from your date of hire. When you enroll in benefits, your benefit choices become effective the first day of the month following your date of hire (i.e., if your date of hire is August 13, the effective date of your benefits is September 1). This Benefits Guide and the tools and plan summaries you will find on the Akima Benefits web site at will help you make informed decisions about your health and welfare benefits and enroll in the choices that are right for you. If you cannot find the answers to your questions in this guide or online, Akima Benefits Center representatives are available to assist you Monday through Friday, between the hours of 7 a.m. and 7 p.m. Central Time, excluding holidays. Be sure to verify and update Verify dependents It is your responsibility to verify that the dependents you plan to cover are, in fact, eligible. Because ineligible dependents can increase the cost of health care coverage significantly for all employees, audits of randomly selected participants whose current benefit coverage includes at least one dependent are conducted routinely. Dependents determined ineligible will not be covered. Beneficiary Information When you enroll, an important step is updating your beneficiary designations. Current, accurate information is critical to ensuring that proper payment is made to your beneficiary designation(s) in the unfortunate event of your death. If you wish to change or add current beneficiaries, you can find the form in the Forms Library when you enroll at Important to Note Enrollment is via the internet. You can access the website at 24 hours a day/7 days a week. See page 2 of this guide if you do not have internet access. After your benefits become effective the first of the month following your date of hire or if you elect to waive benefits, benefit changes are not allowed during the plan year unless you have a qualifying life event. Examples of Qualifying Life Events: Marriage or Divorce Birth or adoption of a child Death of a dependent Medicare entitlement Loss of other coverage If you have a qualifying life event, you must notify the Akima Benefits Center at and provide necessary documentation within 30 days of the event. If you do not do so, you will have to wait until Akima s Open Enrollment to make any changes to your benefits. If You Do Not Take Action If you fail to take action during your enrollment period, you could be automatically enrolled in ( defaulted into) coverage that you do not want, along with any associated cost to you. So, even if you do not want to enroll in benefits, you must go online and waive coverage. Page 1

4 How To Enroll Online enrollment is convenient and secure. The Akima Benefits Center is available online from any computer with internet access 24 hours a day/7 days a week. Enroll online in three easy steps. 1. Log on and sign in Log on to: On the Welcome page select Click Here to create a user name and password. When you access the secure website for the first time, you must create a new account. You will be prompted to setup your user profile by entering identifying information in order to access the Open Enrollment page. Once you are registered and have a user ID and password, the next time you visit the website simply enter them to sign on. 2. Make your choices and enroll You will be able to select from the left navigation bar to make your benefits choices. Add the dependents you wish to enroll, and be prepared to enter their birth dates and social security numbers. Select a benefit in which to enroll, such as medical; then choose coverage levels. Navigate to the previous page or proceed to the next page of each record by selecting PREVIOUS or NEXT. 3. Confirm your elections and enrollment Once you have completed your enrollment and you are satisfied with your enrollment selections, click PRINT CONFIRMATION STATEMENT at the bottom of the page to retain a copy of your elections for your records. Be sure to review your confirmation statement carefully. If your confirmation statement shows that you enrolled yourself or your dependents incorrectly, you may make changes online up to the end of your enrollment period. Enrolling by Telephone The easiest, most convenient way to enroll in your benefits is through the Akima Benefits Center at However, if you do not have Internet access, you can also enroll by calling the Benefits Center at Representatives are available to assist you and answer your questions Monday through Friday, between 7 a.m. and 7 p.m. Central time, excluding holidays. Enrolling in 401(k) benefits Visit the Principal Financial Group online at You must use this website to enroll or change your 401(k) contributions and choose or change investment selections. The first time you access the website, at the Account Login prompt select login type Personal, and then click on Go. On the following Login page, click on Establish Your User Name and Password, to proceed with creating your account. New employees are eligible to participate in the plan immediately. You may also contact Principal by phone at , Monday- Friday from 7 a.m. to 9 p.m. Central time on the days the stock market is open. Note: If you are an employee working on an Akima contract at NIOSH, contact PNC at , Page 2

5 Important Information Health Advocate Services Akima, LLC is pleased to provide you with Health Advocate, the nation s leading advocacy and benefits assistance company. The staff at Health Advocate is comprised of highly experienced healthcare professionals including registered nurses and healthcare administrative experts who work with you one-on-one to help you find solutions to your healthcare or insurance-related issues. There is no cost to you and no form needed to enroll. You will be assigned a Personal Health Advocate to assist you and your immediate family, as well as your parents and parents-in-law regardless if they are covered under your benefits with: Untangling insurance claims and issues Answering diagnostic questions Finding the best doctors and arranging appointments Assisting with elder care Negotiating provider fees Health Advocate can be accessed 24/7, but normal business hours are Monday Friday between 8 am and 9 pm EST. You may contact them by telephone or at the following: Provider: Health Advocates Services answers@healthadvocate.com Website: Phone: Important! You may change your enrollment choices with the Akima Benefits Center up to the end date of your enrollment period, which is within 30 days of your hire date. You can make changes to your 401(k) elections at any time. About This Guide This guide is a basic outline of your benefits and highlights the plans that are part of Akima s Benefits program. This guide does not include all of the details or exclusions that are found in the insurance contracts or official plan documents. If there is a conflict between this guide or the information at and the official Plan Documents, the Plan Documents will govern. Akima reserves the right to amend, modify, or terminate its plans and change costs at any time and without prior notice. Your participation in any of Akima s Benefits Plans does not give you the right to continued or future employment. Plan Summaries Plan summaries are located in this guide and in the Resource Library at Reviewing the summaries and utilizing the other enrollment resources listed here, will help you make informed decisions about your benefits. Misrepresentation It is a crime to knowingly and with intent to injure, defraud, or deceive the plan or your employers or provide any false information, including filing a claim that contains any false, incomplete, or misleading information. These actions will result in denial of your claims, and you may be subject to criminal and/or civil prosecution and punishment under state and/or federal law. The plans reserve the right to pursue all appropriate legal remedies in the event of fraud. Any material misrepresentation on the part of you and/or your dependents in making application for coverage, or any application for reclassification, or any application for service, will render the coverage under this plan null and void. Page 3

6 Your Choices... Health Plans If you are a regular full-time or part-time employee working 30 hours or more, you have two Akima benefit plans from which to choose. The Akima Complete Plan, offering medical, dental, and vision coverage and the Akima D&V Plan, offering dental and vision coverage only. Pages 5 and 6 of this guide provide summary information on these plans. Visit the Akima Benefits Center online at for Summary Plan Descriptions. Akima Complete Plan Anthem Medical Plan Prescription drug plan Delta Dental Plan VSP Vision Plan Akima D&V Plan Delta Dental Plan VSP Vision Plan No medical or prescription drug plan Waiving Medical Coverage If you wish to enroll in the D&V Plan only, you must provide proof that you have medical coverage under another carrier (generally a copy of the front and back of your insurance card, i.e. Tricare, CHAMPVA, etc.). You will be prompted for this proof when you enroll online at You must complete, sign, and return a Benefits Waiver Form that can be found in the Resource Library on the web site. The form will need to be submitted to Akima s Benefits Center via fax Attn: Akima Benefits Center, or akimabenefits@boongroup.com along with a copy of proof of other medical coverage. Life and Disability Plans In addition to the Akima Complete and Akima D&V Plans, all regular full-time or part-time employees who work 30 hours or more per week are eligible to receive life and disability benefits depending upon the Akima company and the project they support. When you enroll online, you will be able to see your eligibility for these benefits and the associated costs. Basic Life and Accidental Death and Dismemberment (AD&D) Supplemental Life (for Employee, Spouse, Children) Short Term Disability Long Term Disability Business Travel Accident (BTA) Insurance Page 4

7 Premera Medical and Prescription Drug Plans Note: All percentages shown are carrier paid percentages, unless otherwise specified. Calendar Year Deductible Calendar Year Out-of-Pocket Maximum MEDICAL PPO PLAN IN NETWORK OUT-OF-NETWORK $500 per individual $1,500 per family $2,000 per individual $6,000 per family $1,000 per individual $3,000 per family $5,500 per individual $16,500 per family Coinsurance 90% 70% Lifetime Maximum Unlimited Unlimited Physician Office Visit $20 copay then 100% Deductible/Coinsurance Preventive Care 100% Deductible/Coinsurance Allergy Injections Deductible/Coinsurance Deductible/Coinsurance Allergy Testing Deductible/Coinsurance Deductible/Coinsurance Hospital Care (Inpatient and Outpatient Professional Services) $20 copay then 100% Deductible/Coinsurance Inpatient Facility Services Deductible/Coinsurance Deductible/Coinsurance Outpatient Surgery Hospital/ Alternative Care Facility Deductible/Coinsurance Deductible/Coinsurance Emergency Room Services (copay at hospital waived if admitted) $75 copay $75 copay Urgent Care Center Services $20 copay Deductible/Coinsurance Chemical Dependency Hospital Based Deductible/Coinsurance Deductible/Coinsurance Outpatient Services $20 copay Deductible/Coinsurance Home Health Care visits per calendar year (in-network and out-ofnetwork combined) Durable Medical Equipment (unlimited)/prosthetics (unlimited)/orthotics ($300 limit per calendar year) Mental Health Treatment Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Inpatient Deductible/Coinsurance Deductible/Coinsurance Outpatient $20 copay Deductible/Coinsurance Rehabilitation Therapy Inpatient (Facilities & Professionals) - 60 visits per calendar year Deductible/Coinsurance Deductible/Coinsurance Outpatient (Facilities & Professionals) - 60 visits per calendar year $20 copay Deductible/Coinsurance PRESCRIPTION DRUGS IN NETWORK OUT-OF-NETWORK Participating Retail Pharmacies - 30 day supply (Member may be responsible for additional cost when not selecting an available generic drug.) Mail Order Pharmacy - 90 day supply (Member may be responsible for additional cost when not selecting an available generic drug.) Specialty Medications (Specialty Medications must be obtained via Premera s Specialty Pharmacy Network in order to receive network level benefits.) 75% up to $2,500 per calendar year, out-of-pocket maximum then 100% (30 day supply*) $15 Generic $25 Preferred Brand $45 Non-Preferred Brand $30 Generic $50 Preferred Brand $90 Non-Preferred Brand *Specialty Pharmacy Only Not Covered Page 5

8 Dental and Vision Plan Summaries DELTA DENTAL PPO PLUS PREMIER PPO PREMIER AND OUT-OF-NETWORK Annual Maximum (per calendar year) $1,250 $1,250 Annual Deductible (per calendar year). No deductible for diagnostic, preventive services, or orthodontic Diagnostic and Preventive Coverage (Exams & cleanings, x-rays, fluoride treatments, sealants) Basic and Major 1 Coverage (Amalgam fillings, extractions, periodontal, scaling, oral surgery, root canal) Major 2 Coverage (Crowns, onlays, dentures, restoration) Orthodontic Coverage (dependent children - up to age 26) $50 individual/ No Family Limit 100% of maximum allowable PPO fee 80% of maximum allowable PPO fee 50% of maximum allowable PPO fee 50% of maximum allowable PPO fee $50 individual/ No Family Limit 80% of maximum allowable fee 70% of maximum allowable fee 50% of maximum allowable fee 50% of maximum allowable fee Orthodontic Maximum Lifetime Coverage per eligible child (up to age 26) $1,500 $1,500 VISION SERVICE PLAN VSP PROVIDER OUT-OF-NETWORK Annual Eye Exam $15 copay - every 12 months Lenses and Frames $25 copay Lenses (single vision, lined bifocal and lined trifocal) Frames Limited to once every 12 months Limited to once every 24 months Select Frames Covered in full up to $130 Contact Lenses (in lieu of lenses/frames) Limited to $130 which includes exam and fitting Additional pair of Prescription Glasses or Sunglasses 20% discount Additional Contact Lenses 15% discount for fitting and evaluation only Laser Surgery Discounts are available Up to $44 Up to $32 single vision Up to $48 lined bifocal Up to $64 lined trifocal Up to $45 Up to $100 Benefit Rates (Semi-Monthly) COVERAGE OPTIONS AKIMA COMPLETE PLAN SEMI-MONTHLY RATE AKIMA D&V PLAN SEMI-MONTHLY RATE Employee $36.37 $3.62 Employee + Child(ren) $66.01 $9.60 Employee + Spouse $72.54 $6.96 Family $ $14.09 Page 6

9 Prudential and Other Insurance Coverages Basic Life Insurance and AD&D When you visit be sure to review your life insurance and disability coverage carefully to determine the options and coverages that best meet your needs. This will help you decide whether you wish to take out additional coverage for you, your spouse and your children. Voluntary Life Insurance for You You may be able to purchase additional life insurance coverage for yourself in increments of $10,000 up to $500,000, not to exceed 5 times your covered annual earnings. Your eligibility may be subject to Evidence of Insurability with a Guaranteed Issue of $150,000 for yourself and $30,000 for your spouse. Note: voluntary life insurance coverage will be reduced as you age, by 35% at age 65 and again by 50% at age 70 as per Prudential s Life Insurance conditions. Voluntary Dependent Life Insurance for Your Spouse You may be able to purchase coverage for your spouse in increments of $5,000 up to $100,000, limited to 50% of employee voluntary supplemental life amount. You must elect voluntary life insurance for yourself in order to elect voluntary life insurance coverage for your spouse. Any voluntary life insurance coverage amounts in excess of the guaranteed issued amounts of $150,000 for employee or $30,000 for spouse will require completion of an Evidence of Insurability form. Enrolling in or increasing the amount of coverage after initial eligibility also will require an Evidence of Insurability form to be completed. Evidence of Insurability forms may be found in the Resource Library online at Voluntary Life Rate Table for Employee and Spouse Ages Monthly rate per $1,000 of coverage Under 25 $ $ $ $ $ $ $ $ $ $ $ $2.324 Voluntary Dependent Life Insurance for Your Child(ren) You will be able to purchase coverage for your child in $2,000 increments up to $10,000, limited to 50% of employee voluntary supplemental life amount and it is all Guarantee Issue [no Evidence of Insurability (EOI) is required for child coverage]. You must elect voluntary life insurance for yourself in order to elect voluntary life insurance for your child. Monthly rate per $1,000 of coverage Child Life $0.054 Business Travel Accident (BTA) All full time Akima employees who work 30 hours or more are covered up to $100,000 by BTA insurance in the event of loss of life while travelling on company business. Page 7

10 Contact Information COMPANY COVERAGE GROUP NUMBER CUSTOMER SERVICE Akima Benefits Center Health Advocate Enrollment Benefits Assistance Client Services Call For questions about enrolling or accessing the benefits website. 7 a.m. to 7 p.m. Central Time, Monday - Friday Call For questions and concerns 7 a.m. to 7 p.m. Central Time, Monday - Friday *Premera Medical Medical Medical Precertification Group # RxBIN Call For questions about your medical claims 10 a.m. to 8 p.m. Central Time, Monday - Friday Rx Provider Services Delta Dental Dental Group# Vision Service Plan (VSP) Prudential Vision Group# Life and AD&D Short Term Disability Long Term Disability Plan# Principal 401(k) Plan # Call For questions about your dental plan. 7:30 a.m. to 7 p.m. Central Time, Monday - Friday Call For questions about your vision coverage. 7 a.m. to 9 p.m. Central Time, Monday - Friday 8 a.m. to 7 p.m. Central Time, Saturday Life Claims Call Disability Claims Call a.m. to 7 p.m. Central Time, Monday - Friday Call For questions about 401(k). 7 a.m. to 9 p.m. Central Time, Monday - Friday PNC Vested Interest 401(k) *Mail claims to: P.O. Box Seattle, WA Plan Wolverine Services, LLC Call For questions about 401(k). 7 a.m. to 9 p.m. Central Time, Monday - Friday Page 8

11 Table of Contents Disclaimer Information What You Should Know...1 Premera Medical and Prescription Drug Plans...5 Benefits Enrollment... Dental and Vision Plan Summaries...6 Be Sure To Verify and Update... Benefit Rates... Important To Note... Prudential and Other Insurance Coverages...7 If You Do Not Take Action... Basic Life Insurance And AD&D... How To Enroll...2 Voluntary Life Insurance For You... Log On And Sign In... Voluntary Dependent Life Insurance For Your Spouse.. Make Your Choices And Enroll... Voluntary Life Rate Table for Employee And Spouse... Confirm Your Elections And Enrollment... Voluntary Dependent Life Insurance For Your Enrolling By Telephone... Child(ren)... Enrolling In 401(k) Benefits... Business Travel Accident (BTA)... Important Information...3 Contact Information...8 Health Advocate Services... Disclosure Information...9 About This Guide... Plan Summaries... Misrepresentation... Important!... Your Choices...4 Health Plans... Waiving Medical Coverage... Life and Disability Plans... Fraud Statement: All enrollees certify that any persons on their applications for coverage are their dependents, as defined under the Plan. They agree that falsification of any statement in their application may bar the right to coverage under the Plan. They certify that the information they have provided is complete, accurate and true. Enrollees must notify their employer when their child(ren), spouse or domestic partner NO longer meet the eligibility requirements as defined under the plan. If a child(ren), spouse or domestic partner no longer meet the plan s definition of eligible they will be no longer eligible for the benefits. If inaccurate or false information is furnished on the application and/or failure to notify the employer that dependent(s) are longer eligible the result could be termination of coverage, non-payment of benefits, recovery of ineligible benefit payments, termination of employment and/or legal action. Patient Protection: Akima s Medical Plan generally does not require the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the Anthem Blue Cross Blue Shield of Missouri at You do not need prior authorization from Anthem Blue Cross Blue Shield or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Anthem Blue Cross Blue Shield of Missouri at Summary of Material Modification (SMM): Please note that this benefit summary is intended to serve as a Summary of Material Modification (SMM), as described in the Employee Retirement Income Security Act (ERISA). Please keep this information with your Certificate of Coverage provided by the carrier. Pre-Existing Condition: The Akima Health Plan has no pre-existing condition clause. Special Enrollment: HIPAA (Health Insurance Portability and Accountability Act) requires that you are made aware regarding special enrollment period. If you acquire a new dependent or decline coverage under the plan while other coverage is in effect and later you lose that coverage for qualifying reasons you have the right to enroll in this plan. Loss of Coverage for Medicaid or a State Children s Health Insurance Program (SCHIP): If you decline to enroll yourself or an eligible dependent (including a spouse) while Medicaid coverage or coverage under a state children s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. You must request to be enrolled within 60 days after you or your dependents coverage ends under Medicaid or the state children s health insurance program. New Dependent by Birth, Adoption or Marriage: If you have a new dependent you may be able to enroll yourself and your new dependents on to this plan. You must request enrollment within 31 days after the birth, adoption or marriage. Eligibility for Medicaid or State Children s Health Insurance Program (SCHIP): If you or your dependents become eligible for a state premium assistance subsidy through state s children s health insurance program or Medicaid you may be able to enroll yourself and your dependents in this plan. You must request enrollment within 60 days after you or your dependents determination of eligibility for such assistance is approved. Women s Health and Cancer Rights Act of 1998 Annual Notice: Under Federal law, group health plans and health insurance issuers providing benefits for a mastectomy must also provide, in connection with the mastectomy for which the participant or beneficiary is receiving benefits, coverage 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 physical complications of mastectomy, include lymph edemas in a manner determined in consultation between the attending physician and the patient. These benefits may be subject to annual deductibles and coinsurance provisions that are appropriate and consistent with other benefits under the coverage. Newborns and Mothers Health Protection Act: Under Federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not 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 delivery. However, the plan or issuer may pay for a shorter stay if the attending physician, nurse midwife or physician assistant, after consultation with the mother, discharges the mother or newborn earlier. Plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour for normal delivery, or 96-hour stay for Cesarean delivery, is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not require that a physician or health care provider obtain authorization for prescribing a length of stay of up to 48-hour for normal delivery, or 96-hour stay for Cesarean delivery. However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain pre-certification. For information on pre-certification, contact your plan administrator. For coverage that is insured, if your state has a law that meets certain criteria, state law applies to your coverage rather than the Newborns Act. A list of states in which the federal Newborns Act requirements apply as of July 1, 1998 can be found in the Newborns Act Questions and Answers: Recent Changes in Health Care Law. Page 9

12 October Park Center Road, Suite 300N Herndon, VA Telephone: Fax: w w w. a k i m a. c o m Non-SCA Edition