Welcome...3. Benefits Notes...4. Medical Plans...6. Health Savings Account (HSAs)...7. Medical Plans...8. Medical Plans...9

Transcription

1 Employee Guide July 1, June 30, 2018

2 Table of Contents Welcome...3 s Notes...4 Medical Plans...6 Health Savings Account (HSAs)...7 Medical Plans...8 Medical Plans...9 Flexible Spending Account (FSA)...10 Dental...11 Vision...11 Voluntary Short Term Disability (STD)...12 Long Term Disability (LTD)...13 Life, Accidental Death, Dismemberment...14 Voluntary Supplemental AD&D...15 Other Voluntary s...15 Other Voluntary s...16 Cobra...17 Employee Payroll Deductions...18 Retirement - 401(k)...19 Notices...20 Please note: The content of this document is solely for informational purposes. Full details for each plan described here can be found in the respective carrier Summary Plan Documents (SPD s). In case of error, discrepancy or omission, carrier Plan Documents and SPD s will govern. Page 2

3 Welcome Contact Information If you need assistance or additional explanations regarding your benefits, you may contact your HR Manager or our benefits broker, McQuade Consulting at: McQuade Consulting (410) , Ext. 0 You may also call the benefit provider directly, by using the contact information provided below. Provider Web Address Phone Number Medical CoreSource Connect mycoresource.com (855) Dental & Vision CoreSource Connect mycoresource.com (855) HSA CoreSource Connect mycoresource.com (855) Life & Disability Insurance Reliance Standard reliancestandard.com (800) Employee Assistance Program LifeCare lifecare.com (800) Flexible Spending Account CoreSource Connect mycoresource.com (855) (k) TransAmerica mariner.trsretire.com (800) Prescription Coverage CVS CareMark caremark.com (800) Telemedicine Teledoc teledoc.com (800) Page 3

4 s Notes Eligibility You are eligible to participate in the s Program if you are working 30+ hours per week. s become effective the 1st of the month following 30 days from your date of hire. Election Changes For purposes of healthcare plans (medical, dental and vision) benefit elections will remain in effect and cannot be changed until the next Open Enrollment period, unless you have a Qualifying Election Change. Qualifying Election Changes must be reported to your Human Resource Representative within 30 calendar days of the date of the event. Qualifying Election Changes Include: Marriage or Divorce Commencement or termination of a recognized domestic partnership Birth or adoption Death of a spouse or a dependent Commencement or termination of spouse s employment Change in job status of you or your spouse (change from part-time to full-time or vice versa) Your dependent child becomes ineligible for coverage A court order requires that your child receive accident or health coverage under this plan or former spouse s plan You, your spouse, or dependent becomes entitled to Medicare or Medicaid You have a Special Enrollment Right There is a significant change in the cost of coverage for you or your spouse attributable to your spouse s employment Notice Regarding Special Enrollment If you are waiving enrollment in the medical plan for yourself or your dependents (including your spouse) because of other health insurance coverage, you may enroll yourself or your dependents in a health plan if you request enrollment within 30 days of your other coverage ending. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents provided that you request enrollment within 30 days of the marriage, birth, adoption or placement for adoption. Page 4

5 Health Care Reform Updates Beginning in 2011, several changes in health care regulations will affect the way certain aspects of the health care industry are treated. It is important that, as an employee, you understand these changes and how they impact your health insurance benefits. Adult children coverage allowed to age 26 First dollar coverage ( no charge ) for preventive care Unlimited Lifetime Maximum Tax penalty for non-qualified HSA distributions increased from 10% to 20% Over-the-Counter medications are no longer treated as non-taxable unless prescribed by a doctor Note: This is meant to be an overview only. Please contact your HR administrator or McQuade Consulting with more detailed questions. Page 5

6 Medical Plans CoreSource administers the medical benefits. Three medical plans are offered through the Cigna network. Cigna offers a broad national network of providers, and no PCP elections are required. PPO HSA (High Deductible Health Plan with Health Savings Account) Plan Year Annual Deductible Out-of-Pocket Maximum Preventive Care Teledoc Visits Primary Care Office Visits Specialist Office Visits Urgent Care Individual: $ 1,300 Family : $2,600 Individual: $2,500 Family : $5,000 $0 Copay In-Network Deductible, then $0 Copay Deductible, then 10% of the Allowed Deductible, then 10% of the Allowed Deductible, then 10% of the Allowed Individual: $2,500 Family: $5,000 Individual: $5,000 Family : $10,000 Out-Of-Network Deductible, then 30% of the Allowed Deductible, then 30% of the Allowed Deductible, then 30% of the Allowed Deductible, then 30% of the Allowed Deductible, then 30% of the Allowed Emergency Room Deductible, then 10% of the Allowed Paid as In-Network Prescription Drug Deductible, then $15/$35/$60 Deductible, then $15/$35/$60 Inpatient Hospital Services Outpatient Lab and X-Ray Diagnostic Major Freestsanding Center Diagnostic Major Outpatient Hospital Deductible, then 10% of the Allowed Deductible, then 10% of the Allowed Deductible, then 10% of the Allowed Deductible, then 10% of the Allowed Deductible, then 30% of the Allowed Deductible, then 30% of the Allowed Deductible, then 30% of the Allowed Deductible, then 30% of the Allowed This is a High Deductible Health Plan that enables enrollees to contribute to a Health Savings Account (HSA). Mariner Finance will also contribute to the employee HSA account, if the employee elects coverage under this medical plan. Coverage Level Mariner Finance s Contribution Employee Only Employee, Employee & Spouse/Domestic Partner, Employee & Child, Family $500 $1,000 Page 6

7 Health Savings Account (HSAs) An HSA (Health Savings Account) is an innovative tool for managing the cost of health benefits. Designed by the federal government, HSA legislation allows individuals to save for future qualified medical and retiree health expenses on a tax-free basis. How an HSA Works 1. Employee enrolls in the PPO HSA plan. 2. Employee makes decisions about how much money pretax they will contribute to their HSA account. 3. HSA funds accrue and are available for reimbursement of qualified expenses and/or remain available for the future. For a list of eligible expenses visit Advantages from the Employee Perspective 1. Amounts contributed by the employee to an HSA belong to the employee, and are portable should their employment terminate. 2. Employees may accumulate tax free earnings on their account. 3. Employees may choose from a range of investment options for HSA contributions. HSA Bank Investment Platform - TD Ameritrade Broker Services - Devenir Mutual Funds Account Funds distributed from the HSA are not taxed if they are used to pay for qualified medical expenses, and any unused funds accumulate tax-free for future use. Tax s, Deductible Requirements & Contribution Limits Tax Deductible: Contributions to the HSAs are 100% tax deductible (for the person making the contribution) Tax-Deferred: Interest earnings accumulate tax-deferred Tax Free: Withdrawals for qualified medical expenses are never taxed. Single Family IRS Maximum Annual Contribution $ 3,400 $ 6,750 Coverage Level Employee Only Employee, Employee & Spouse/Domestic Partner, Employee & Child, Family Mariner Finance s Contribution $500 $1,000 Note: Individuals age 55 and over may contribute an additional $1,000 for catch-up. Caution: Mariner Finance cannot give employees tax advice Employees should consult their own tax advisor. Daily Use of HSA Doctor, Specialist, Hospital, Lab, etc. Member should use HSA Debit card for all IRS qualified medical costs or risk paying penalties. To learn more about health savings account please visit Pharmacy Always show ID card! Pharmacist will submit claim to carrier and member will be responsible for discounted price while still meeting the deductible. After deductible has been met, member is responsible for copay only. Member should use HSA debit card for all qualified prescribed medication costs. Page 7

8 Medical Plans This plan is administered by CoreSource and offered through the Cigna network. PPO 80/60 Plan Year Annual Deductible Out-of-Pocket Maximum Individual: $750 Family : $1,500 Individual: $2,500 Family : $5,000 In-Network Individual: $1,500 Family: $3,000 Individual: $7,500 Family : $15,000 Out-Of-Network Preventive Care Deductible, then Copay $0 Deductible, then 40% of the Allowed Teledoc Visits $0 Copay Deductible, then 40% of the Allowed Primary Care Office Visits $20 Copay Deductible, then 40% of the Allowed Specialist Office Visits $30 Copay Deductible, then 40% of the Allowed Urgent Care $30 Copay Deductible, then 40% of the Allowed Emergency Room Deductible, then 20% of Allowed Paid as In-Network Prescription Drug $10/$25/$45 $10/$25/$45 Inpatient Hospital Services Deductible, then 20% of Allowed Deductible, then 40% of Allowed Outpatient Lab and X-Ray Diagnostic Major Freestsanding Center Diagnostic Major Outpatient Hospital X-ray: Ded, then 20% of Allowed Lab: $30 Copay Deductible, then 20% of the Allowed Beneift Deductible, then 20% of the Allowed Beneift X-ray & Lab: Deductiblel, then 40% of Allowed Benfit Deductible, then 40% of the Allowed Beneift Deductible, then 40% of the Allowed Page 8

9 Medical Plans This plan is administered by CoreSource and offered through the Cigna network. PPO 100/60 Plan Year Annual Deductible Out-of-Pocket Maximum Individual: $500 Family : $1,000 Individual: $2,000 Family : $4,000 In-Network Individual: $1,500 Family: $3,000 Individual: $4,000 Family : $8,000 Out-Of-Network Preventive Care $0 Copay Deductible, then 40% of Allowed Teledoc Visits $0 Copay Deductible, then 40% of Allowed Primary Care Office Visits $20 Copay Deductible, then 40% of Allowed Specialist Office Visits $30 Copay Deductible, then 40% of Allowed Urgent Care $50 Copay Deductible, then 40% of Allowed Emergency Room $200 Copay, (waived if admitted) Paid as In-Network Prescription Drug Out-of-Pocket $15/$35/$60 $15/$35/$60 Inpatient Hospital Services Deductible, then $300 Copay per admit Deductible, then 40% of Allowed Outpatient Lab and X-Ray $0 Copay Deductible, then 40% of Allowed Diagnostic Major Freestsanding Center Diagnostic Major Outpatient Hospital $0 Copay Deductible, then 40% of Allowed Deductible, then $300 Copay per admit Deductible, then 40% of Allowed Page 9

10 Flexible Spending Account (FSA) A Flexible Spending Account (FSA) increases your take-home pay by reducing your taxable income. An FSA allows you to save up to 30% on your eligible healthcare and/or dependent care expenses every year by using pre-tax dollars. FSA plan options: Medical FSA - May be used for eligible medical, dental and vision expenses by employees who elect coverage under the PPO 80/60 or the PPO 100/60 Limited FSA - PPO HSA plan members do not qualify for a Medical FSA but can enroll in a Limited Purpose FSA and use funds for eligible Dental and Vision expenses Dependent Care FSA - May be used on eligible child care expenses (preschool, before or after school programs and child or adult daycare) How it Works When you choose to enroll in a Healthcare or Dependent Care FSA, you choose the dollar amount you want to contribute to each account based on your estimated expenses for the upcoming Plan Year. Your contributions will be deducted in equal amounts from each paycheck, pre-tax, throughout the Plan Year. You will receive a debit card in the mail to pay for eligible expenses. Annual contribution maximum: Medical FSA - $2,600 Limited FSA - $2,600 Dependent Care FSA - $5,000 Your total Healthcare FSA annual contribution amount is available immediately at the start of the Plan Year; Dependent Care FSA funds are available up to the current account balance only. FSA Eligible Expenses FSA funds may only be used for eligible expenses under you healthcare FSA and/or dependent care FSA. Some eligible expenses include: Medical care services Dental care services Vision care expenses Prescriptions Daycare Tuition More detailed lists can be found at in IRS Publications 502 & 503. Please note insurance premiums are NOT eligible for reimbursement. Important Considerations FSA Funds do not Rollover: It is important to be conservative in making elections because any unused funds left in your FSA at the close of the Plan Year are not refundable to you. (The only exception to this rule is for the Healthcare FSA where funds may carryover to the next Plan Year s healthcare FSA (up to $500).You are urged to take precautionary steps, such as tracking account balances, to avoid having funds remaining in your account at year-end. Changing Elections During the Plan Year: You may change your FSA elections during the Plan year ONLY if you experience a qualifying change of status such as: a marriage or divorce birth or adoption of a child, or a change in employment status Page 10

11 Dental CoreSource administers the dental benefits. The dental plan is offered through the Cigna network. Plan Year Deductible In-Network Individual: $50 Family : $150 Out-Of-Network Plan Year Maximum $1,000 Preventive Care (Deductible Waived) No charge for Allowed s No charge for Allowed s Basic Care Major Care Orthodontia Beneift (Dependent children to the end of the month the turn 19) Child Orhodontia Deducitble, then 20% of Allowed Deductible, then 50% of Allowed Deductible, then 20% of Allowed Deductible, then 50% of Allowed Lifetime Deductible: $50 Lifetime Maximum: $1,000 Lifetime Deductible, then 50% of Allowed to Lifetime Max Vision CoreSource administers the vision benefits. The vision plan is offered through the VSP network. In-Network Out-Of-Network Exam (every 12 months) $10 Copay Covered up to $45 Lenses (every 12 months) Single Vision Lenses Covered in full Reimbursed up to $52 Bifocal Lenses Covered in full Reimbursed up to $82 Lenticular Lenses Covered in full Reimbursed up to $181 Frames (every 12 months) Exclusive Tower Collection - $0 Copay (approx 270 frames) Covered up to $45 Contact Lenses (in lieu of eyeglasses) Medically Necessary Covered in full w/ prior approval Reimbursed up to $285 w/prior approval Conventional/Disposable Covered up to $97 Reimbursed up to $97 Page 11

12 Voluntary Short Term Disability (STD) Mariner Finance recognizes that disabilities can have a major impact on employee s life and finances. To ensure some of your weekly income will continue if you are unable to work we offer Short Term Disability coverage. Coverage is 100% employee paid Weekly benefit amount equal to 40%, 50% or 60% of pre-tax covered earnings, up to maximum benefit of $1,250 per week Injury (accident) and Sickness (illness): benefits begin on the 15th consecutive day of disability period up to 11 weeks Employees who waive enrollment when initially eligible are considered late entrants and will require a statement of insurability (a medical questionnaire used to determine if you will be approved for coverage) Preexisting Conditions Exclusion - STD STD benefits will not be paid for a disability caused by a pre-existing condition during the first 12 consecutive months of coverage, if pre-existing condition was diagnosed in the 3 months immediately prior to the effective date. A pre-existing condition is defined as a sickness or illness for which you received medical treatment, consultation, care or services including diagnostic measures, or had taken prescribed drugs or medicines in the three months prior to your effective date. Example: Employee Date of Hire: 05/05/2017 s Effective Date: 07/01/2017 If you are treated for a pre-existing condition within the 3 months prior to July 1, 2017 (April 1 - June 30), that specific condition would not be covered for the first 12 months you are enrolled. Any newly treated or diagnosed disability or injury would be covered as of July 1, Page 12

13 Long Term Disability (LTD) Long Term Disability insurance provides benefits for long term disabilities from a covered illness or injury. Coverage is 100% employer paid Monthly benefit amount equal to 60% of covered earnings, up to a maximum benefit of $6,000 per month Elimination period 90 consecutive days of total disability Survivor - 3 months Own Occupation Coverage - 24 months Residual and Partial Disability Work Incentive & Child Care Provisions Pre-Existing Condition Limitation - LTD benefits will not be paid for a disability caused by a pre-existing condition during the first 12 consecutive months of coverage, if pre-existing condition was diagnosed in the 3 months immediately prior to the effective date. If you are symptom or condition free for the first 6 months after the effective date the second six month exclusion is eliminated and the disability will be covered right away. s will not extend beyond the longer of: Social Security Normal Retirement Age (SSNRA) or Duration of s below: Age at Disablement 61 or less to age /2 years 63 3 years /2 years 65 2 years /4 years /2 years /4 years 69 or more 1 year 1 year Duration of s Page 13

14 Life, Accidental Death, Dismemberment Basic Life and AD&D Insurance Life Insurance provides financial protection for your family in the event of your death. Mariner Finance provides Basic Life and Accidental Death & Dismemberment (AD&D) Insurance coverage to active employees working a minimum of 30 hours per week, excluding employees working on a temporary or seasonal basis. Basic Life and AD&D Insurance is provided at no cost to the employee. For increased protection, you may purchase Supplemental Life Insurance coverages for you and your family. Employee Basic Life and AD&D Insurance Premiums paid by employer Portability Amount: 2X basic annual earnings, rounded to the next highest $1,000, to a maximum of $200,000. Guaranteed issue - Employee: 2x basic annual earnings not to exceed $200,000, Spouse: $30,000, all child amounts are guarantee issue. AD&D : equal to your basic life insurance amount. The AD&D is paid if an employee is injured as a result of an accident, and that injury is independent of sickness and all other causes. Supplemental Life Insurance Employee Supplemental Life Insurance To supplement your Basic Life Insurance coverage, you may purchase Supplemental Employee Life Insurance in multiples of $10,000 up to a maximum of $500,000. Premiums paid by Employee Guarantee Issue Amount: $200,000 Age Reduction Schedule: 65% at age 65, 50% at age 70 Spousal Life Insurance If you purchased Supplemental Employee Life Insurance for yourself, you may purchase life insurance coverage for your spouse or domestic partner in multiples of $10,000 up to a maximum of $500,000 Premiums paid by employee Guarantee Issue Amount: $30,000 Age Reduction Schedule: 65% at age 65, 50% at 70 Dependent Life Insurance If you purchased Supplemental Employee Life Insurance for yourself, you may purchase life insurance coverage for your dependent child(ren) in multiples of $5,000 up to a maximum of $10,000, not to exceed 100% of employee s amount. Minimum benefit: $5,000 Premiums paid by Employee Dependent: unmarried child(ren) from 14 days to age 19, or through age 25 if the child is a fulltime registered student. Employee and Spousal Supplemental Life Rates Per $1,000 Age Employee Rate Spouse Rate $ $ $ $ $ $ $ $ $ $ $0.165 $ $ $ $0.430 $ $ $ $ $ $1.678 $1.678 *Employees who waive enrollment when initially eligible are considered late entrants and will require a statement of insurability (a medical questionnaire used to determine if you will be approved for coverage) Page 14

15 Voluntary Supplemental AD&D Voluntarty Supplemental Accidental Death & Dismemberment (AD&D) Insurance If you purchase Voluntary Supplemental AD&D Insurance for yourself, you may purchase Voluntary Supplemental AD&D coverage for your dependents. Premiums paid by Employee Premiums based upon your age and amount of insurance you have selected s option are available from $10,000 to a maximum f $500,000 in increments of $10,000 reduction schedule: 50% at age 75, 25% at age 80 Other Voluntary s AccidentAdvance Accident insurance pays cash benefits directly to you to help supplement out-of-pocket expenses that you may incur especially with high deductible medical plans. 100% Employee paid (payroll deducted) Pays benefits directly to you Family options available Below are a few examples of the Accident Reimbursement. Accident Emergency Treatment Reimbursement Accident Emergency Treatment $250 Major Diagnostic Examination (Ex. MRI, EEG) $400 Ambulance Ground $180/ Air $900 Initial Accident Hospitalization $120 tm Rates Accident Insurance Rate Frequency Employee Employee & Child(ren) Employee & Spouse Family Voluntary Accident Advance Bi-weekly $5.51 $7.58 $8.49 $10.82 Page 15

16 Other Voluntary s Hospital Select II - Hospital Indemnity Insurance Hospital Indemnity insurance pays cash benefits directly to you in the event you are hospitalized to help supplement out-of-pocket expenses that you may incur especially with high deductible medical plans. 100% Employee paid (payroll deducted) Pays benefits directly to you Family Options available Daily In-Hosptial Indemnity Pays each day an insured person is confined to a hospital (but not emergency room outpatient stay or stay in an observation unit) as the result of a covered accident or sickeness - 31 day calendar year max Reimbursement $100 Intensive Care Indemnity Rider - 30 day calendar year max $200 Hospital Confinement Indemnity Rider - 1 day per confinement/ 1 day(s) per calendar year max $500 Ambulance Indemnity Rider - 3 days per calendar year max $100 Inpatient Surgical Indemnity Rider, if anesthesia is administered, pays additional 30% - 1 day calendar year max $500 Rates Hospital Select Frequency Employee Employee & Spouse Employee & Child(ren) Family Voluntary Hospital Select Bi-weekly $11.93 $26.03 $19.68 $31.12 Page 16

17 Cobra Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, COBRA qualified beneficiaries (QBs) generally are eligible for group coverage during a maximum of 18 months for qualifying events due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. COBRA coverage is not extended for those terminated for gross misconduct. Upon termination, or other COBRA qualifying event, the former employee and any other QBs will receive COBRA enrollment information. Qualifying events for employees include voluntary/involuntary termination of employment, and the reduction in the number of hours of employment. Qualifying events for spouses or dependent children include those events above, plus, the covered employee s becoming entitled to Medicare; divorce or legal separation of the covered employee; death of the covered employee; and the loss of dependent status under the plan rules. If a QB chooses to continue group benefits under COBRA, they must complete an enrollment form and return it to the Plan Administrator with the appropriate premium due. Upon receipt of premium payment and enrollment form, the coverage will be reinstated. Thereafter, premiums are due on the 1st of the month. If premium payments are not received in a timely manner, federal law stipulates that your coverage will be canceled after a 30-day grace period. If you have any questions about COBRA or the Plan, please contact the Plan Administrator. Please note that if the terms of the Plan and any response you receive from the Plan Administrator s representatives conflict, the Plan document will control. Page 17

18 Employee Payroll Deductions Per pay contributions are based on 26 pay periods. Medical PPO 100/60 PPO 80/60 PPO HSA* Employee $98.34 $81.03 $57.66 Parent & Child(ren) $ $ $96.30 Employee & Spouse $ $ $ Family $ $ $ * This is a High Deductible Health Plan that enables enrollees to contribute to a Health Savings Account (HSA). Mariner Finance will also contribute to the employee HSA account, if the employee elects coverage under this medical plan. Coverage Level Mariner Finance s PPO HSA Contribution Employee Only Employee, Employee & Spouse/Domestic Partner, Employee & Child, Family $500 $1,000 Dental Employee $14.31 Parent & Child(ren) $22.90 Employee & Spouse $32.92 Family $41.51 Vision Employee $2.48 Parent & Child(ren) $3.94 Employee & Spouse $5.70 Family $7.18 Page 18

19 Retirement - 401(k) TransAmerica To be eligible to contribute to the 401(k) retirement plan, you must be: At least 21 years of age Employed for 90 days (from original date of hire) Pre-tax and Post-tax contribution (Roth) plans are available Newly eligible employees are automatically enrolled in the plan at a 3% contribution rate Contribution levels and/or investment options can be changed at any time Employer Contribution Matching Contributions of 1-3% are matched 100% Additional 1-2% contributions are matched at 50% Page 19

20 Notices THE FOLLOWING NOTICES ARE INCLUDED IN THIS COMMUNICATION IN THIS ORDER: WHCRA Notice (Women s Health and Cancer Rights Act) CHIPRA Notice (Children s Health Insurance Program Reauthorization Act) Patient Protection Choice of Providers HIPAA Special Enrollment Rights Notice Newborn s Mother s Health Protection Act NOTICE OF RIGHTS UNDER THE WOMEN S HEALTH AND CANCER RIGHTS ACT (WHCRA) 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 your Employer Representative for more information. 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 lymphedemas. These benefits will be provided subject to the same deductible and co-insurance particulars that are applicable to other medical and surgical benefits provided under this Plan. For more information or to get a copy of the Summary Plan Description containing these details contact your Employer Representative. 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 of 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 January 31, To see if any other states have added a premium assistance program since January, or for more information on special enrollment rights, contact either: Contact your State for more information on eligibility U.S. Department of Labor U.S. Department of Health and Human Services Employee s Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Menu Option 4, Ext OMB Control Number (expires 10/31/2016) Page 20

21 Alabama - Medicaid Minnesota - Medicaid Pennsylvania - Medicaid Website: Phone: Website: Click on Health Care, then Medical Assistance Phone: Website: Phone: Alaska - Medicaid Missouri - Medicaid Rhode Island - Medicaid Website: programs/medicaid/ Phone: Phone (Anchorage): Website: Phone: Website: Phone: Colorado - Medicaid Montana - Medicaid South Carolina - Medicaid Website: Customer Contact Center: Website: Phone: Website: Phone: Florida - Medicaid New Hampshire - Medicaid South Dakota - Medicaid Website: Phone: Website: hippapp.pdf Phone: Website: Phone: Georgia - Medicaid New Jersey - Medicaid & Chip Texas - Medicaid Website: - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: Website: dmahs/clients/medicaid/ Medicaid Phone: CHIP Website: index.html CHIP Phone: Website: Phone: Indiana - Medicaid New York - Medicaid Utah - Medicaid & Chip Website: Phone: Website: medicaid/ Phone: Medicaid: CHIP: Phone: Iowa - Medicaid North Carolina - Medicaid Vermont - Medicaid Website: Phone: Website: Phone: Website: Phone: Kansas - Medicaid North Dakota - Medicaid Virginia - Medicaid & Chip Website: Phone: Website: medicalserv/medicaid/ Phone: Medicaid Website: programs_premium_assistance.cfm Medicaid Phone: CHIP Website: CHIP Phone: Kentucky - Medicaid Nebraska - Medicaid Washington - Medicaid Website: Phone: Website: Phone: Website: premiumpymt/pages/ index.aspx Phone: ext Louisiana - Medicaid Nevada - Medicaid West Virginia - Medicaid Website: Phone: Medicaid Website: Medicaid Phone: Website: Phone: , HMS Third Party Liability Maine - Medicaid Oklahoma - Medicaid Wisconsin - Medicaid & Chip Website: public-assistance/index.html Phone: TTY Website: Phone: Website: Phone: Massachusetts - Medicaid & Chip Oregon - Medicaid Wyoming - Medicaid Website: Phone: Website: Phone: Website: equalitycare Phone: Page 21

22 PATIENT PROTECTION CHOICE OF PROVIDER In cases where the Group Health Plan allows or required a participant to designate a primary care provider, the participant has the right to designate any primary care provider who participates in the network and who is available to accept the participant or participant s family members. Until you make this designation, the Group Health Plan may designate a primary care provider automatically. For information on how to select a primary care provider, and for a list of the participating primary care providers, you can contact your Employer Representative. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from the Group Health Plan 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 your Employer Representative. HIPAA SPECIAL ENROLLMENT RIGHTS NOTICE If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents other coverage). However, you must request enrollment within 30 days after you or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact your Employer Representative. NEWBORN S AND MOTHER S 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 issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours if applicable) info@mcquadeconsulting.com Page 22