April 28, 2015 JANE SAMPLE 1111 SW STREET CIR ANYTOWN OR 97000

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1 April 28, 2015 JANE SAMPLE 1111 SW STREET CIR ANYTOWN OR Re: Your Coverage Options PacificSource Policy #: G PacificSource Member ID #: We ve learned that you and/or your dependents have recently changed to a new health insurance company, or lost coverage under a PacificSource health plan. If you ve changed to a new health insurance company, we d like to thank you for the opportunity to serve you, and hope we can help with your insurance needs again in the future. As you have insurance coverage in place, you likely won t need the contents of this packet. If you ve lost coverage, this packet contains information you ll need to help you get new coverage. We encourage you to keep it with your other health insurance documents. Here s what s enclosed: Certificate of Prior Health Insurance Coverage. This document provides evidence of lost coverage. Lost coverage may qualify you for a special enrollment period for individual coverage through your state s Marketplace. The Certificate may also serve as proof of prior coverage to satisfy waiting periods for new insurance or other purposes. Statement of HIPAA Portability Rights: This notice explains your healthcare-related rights and protections under federal law. Need Individual or Family Health Coverage? : This PacificSource flier gives you an overview of how we can help you find new health insurance that best fits your needs and budget - whether you purchase directly through us or through your state s Marketplace. After reviewing these materials, you re welcome to contact us if you have any questions, or would like help finding new individual coverage. Our Coverage Advisors are available by phone toll-free: (855) , or by individual@pacificsource.com. It would be our pleasure to continue to serve you with your health insurance needs in the future. Enclosures OR

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3 April 28, 2015 JANE SAMPLE 1111 SW STREET CIR ANYTOWN OR Certificate of Prior Health Insurance Coverage We are pleased to provide you with this Certificate of Prior Health Insurance Coverage. This document is evidence that you or your dependent(s) had health insurance coverage with us. It may be useful for: Providing evidence for dates when coverage ended. Loss of coverage may qualify you for a special enrollment period through your state s individual health insurance Marketplace. Providing proof of prior health insurance coverage to satisfy waiting periods for other types of insurance. Questions? Our Customer Service team would be happy to answer any questions about this certificate. Contact us by phone toll-free at (888) , or by at cs@pacificsource.com. PacificSource Certificate of Prior Insurance Coverage Certificate date: April 28, 2015 Group number: G Subscriber name: Jane Sample Group name: Sample Company Name Member Name Jane Sample Member ID Number Date Coverage Began Date Coverage Ended January 01, 2009 April 30, 2015 Pat Sample January 01, 2009 April 30, OR

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5 STATEMENT OF HIPAA PORTABILITY RIGHTS This statement outlines your rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Under HIPAA, you may need evidence of your coverage to reduce a waiting period for coverage. The Affordable Care Act (ACA) prohibits group health plans and insurance issuers from excluding you from coverage for a medical condition and imposing pre-existing conditions. However, some dental and other insurance coverage may still have waiting periods associated with care. Any prior creditable coverage you ve had may reduce the length of such waiting periods. Most health coverage, including group health plan coverage, COBRA or state continuation coverage, coverage under an individual health policy, Medicare, Medicaid, State Children's Health Insurance Program, and coverage through high-risk pools and the Peace Corps, is considered creditable coverage. You can add together all creditable coverage you have and apply it to a waiting period. However, if at any time you went for 63 days or more without any coverage (called a break in coverage), a plan may not have to count the coverage you had before the break. Therefore, once your coverage ends, you should try to obtain other coverage as soon as possible to avoid a 63-day break. You can request a certificate of creditable coverage from your health insurance plan when your coverage under that plan ends. HIPAA Right to special enrollment in another plan: If you lose your group health plan coverage, you may qualify for "special enrollment." This means that you may be able to get into another group health plan (such as a spouse's plan), even if the plan generally does not accept late enrollees. You would need to meet the plan's regular eligibility requirements and request enrollment within 30 days of losing your coverage. (Additional special enrollment rights may be triggered by marriage, birth, adoption, and placement for adoption). ACA Right to special enrollment in another plan: The ACA requires a 60 day special enrollment period for qualifying events of marriage, birth, adoption, and placement for adoption. Prohibition against discrimination based on a health factor: A group health plan may not keep you (or your dependents) out of the plan based on certain health factors. Also, a group health plan may not charge you (or your dependents) more for coverage, based on those health factors, than the amount they would charge a similarly situated individual. HIPAA Right to individual health coverage: If you are an "eligible individual," you have a right to buy certain individual health policies (or in some states, to buy coverage through a high-risk pool) without having a pre-existing condition waiting period. To be an eligible individual, you must meet the following requirements: You have had coverage for at least 18 months without a break in coverage of 63 days or more; Your most recent health coverage was under an employer-sponsored group, church or government health plan; Your group coverage was not terminated because of fraud or nonpayment of premiums; You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits (or continuation coverage under a similar state provision); and You are not eligible for another group health plan, Medicare, or Medicaid, and do not have any other health insurance coverage. HIPAA.Notice.0415

6 The right to buy individual coverage is the same whether you are laid off, fired, or quit your job. Therefore, if you are interested in obtaining individual coverage and you meet the eligibility criteria shown above, you should apply for coverage as soon as possible to avoid losing your eligibility due to a 63-day break. ACA Guaranteed issue and renewability: The ACA requires health insurers to permit enrollment regardless of health status, age, gender, or other factors that might predict the use of health services. You may enroll in individual health coverage inside or outside of your state s Health Insurance Exchange. As long as you continue to pay your premiums, your insurance issuer must offer to renew your policy. Additional protections under federal law: Health insurers may not impose a pre-existing condition period of more than 12 months, for plan years beginning prior to January 1, 2014 and Grandfathered plans. For more information. If you have questions about your HIPAA rights, you may contact your state insurance department or the U.S. Department of Labor (DOL), Employee Benefits Security Administration (EBSA) toll-free at (866) (for free HIPAA publications, ask for publications concerning changes in healthcare laws). You may also contact the CMS publication hotline at (800) (ask for "Protecting Your Health Insurance Coverage"). These publications and other useful information are also available on the Internet at or HIPAA-Administrative-Simplification/HIPAAGenInfo/index.html. HIPAA.Notice.0415

7 Need Individual or Family Health Coverage? We Can Help. If you ve recently lost your health insurance, we d be happy to help you explore your options. We offer a full line of individual and family plans to fit your needs, either directly through us, or through the new exchange marketplace. We want to make it easy for you to stay with us as a PacificSource member. Peace of Mind, Made Easy Our individual and family plans make it easy to get the preventive care you need to help you stay well, and protect you from the high costs of unexpected medical expenses. PacificSource individual plans offer a range of premiums and deductibles so you can find the coverage that fits you best. We have more than 46,300 providers across our networks to give you the maximum choice of doctors and other healthcare professionals. We re known for taking good care of people. Choosing an individual and family plan with us means you can stay with us, and have access to our award-winning customer service, Real people always answer the phone. You ll have access to the tools to manage your coverage so you can get the information you need, when and where you need it. Not sure where to start? Our knowledgeable and friendly Coverage Advisors are happy to help. At no cost to you, Coverage Advisors can: Help you navigate your options and find a health plan that fits your family s needs and budget Show you how to find out if you qualify for tax credits to help pay for coverage through your state s Marketplace Refer you to a local insurance agent for additional no-cost assistance Provide you with a quote for new coverage through an individual or family plan Coverage Advisors are available by phone toll-free: (855) , or by individual@pacificsource.com. Ready to compare plans and enroll? Our plans are available: Direct from us Through your health insurance agent Through your state s health insurance Marketplace If you prefer, you can conveniently compare plans, get rates, and enroll online by visiting PacificSource.com/ find-an-individual-plan. You ll find all of the information you need, including deductibles, provider networks, health and wellness programs, no-cost extras, and more. Just select your state and follow the on-screen instructions to complete and submit your application. Thank you. We look forward to continuing to provide you and your family with the health insurance coverage, tools, and one-on-one service you need to live your healthiest life!

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