RICHMOND COMMUNITY SCHOOL Employee Benefit Trust 2018 Open Enrollment Guide

Transcription

1 RICHMOND COMMUNITY SCHOOL Employee Benefit Trust 2018 Open Enrollment Guide 1

2 Introduction Richmond Schools is excited about the upcoming year and all the opportunities for the company and it s employees to thrive. Richmond Schools and Dunn & Associates have worked collectively to develop an impressive health plan for all eligible employees and their eligible dependents. We are committed to providing plan participants with access to great benefits. This provides information to you to help you enroll into the plan. With this you will receive an enrollment form. Please fill the form out and return it to your Human Resource Department no later than 11/27/2017. If you have difficulty filling out the form or have questions about benefits, deductions or anything else, please don t hesitate to call Dunn & Associates. Open Enrollment An open enrollment period shall be held annually during the month of November. During this open enrollment period, Employees who have not previously elected coverage under the Plan and who do not qualify for a Special Enrollment Period as described herein, may enroll for coverage for themselves and/or any eligible Dependents. Coverage shall be effective on January 1 for Employees or Dependents who enroll during an open enrollment period. All Plan provisions shall apply to an Employee or Dependent who enrolls in the Plan during an open enrollment period. During an open enrollment period you may: 1) Change your plan elections for medical, dental, vision and basic life; 2) Add/delete coverage for your spouse or dependent children. 2

3 General Information Dunn & Associates Contact Information PO Box 2369 Columbus, IN Phone: (800) or (812) Fax: (812) Benefit Analyst Julia Karles; Senior Benefit Analyst Jennie Blystone; Claims Manager Dee Jessee; Identification Card Each employee enrolling for the first time will receive an ID card. Families will receive two cards. If additional cards are need for dependents, please contact your Personnel Department or Dunn & Associates. Submission of Claims In most cases, hospitals and doctors directly bill to the address on the back of your ID card. Claims forms will not be necessary in these cases. If you wish to submit the claim yourself, claim forms will be available from your Human Resource Department or Dunn & Associates. The claims should be mailed to the address on the back of your ID card. Dunn Online Dunn & Associates is committed to personal touch customer service; however, we know that some people also want to have the option of obtaining information concerning their benefit plan via the internet. For this reason, we offer Dunn Online. Visit 3

4 General Information Precertification Call Clinix at (800) prior to receiving the following services to receive maximum benefits payable under the plan. Call within 48 hours if an emergency. Inpatient stays greater than 23 hours; Outpatient procedures requiring use of an anesthesiologist or a nurse anesthetist; Home Health Care Pregnancies Cancer Care (chemotherapy/radiation/surgery) MRI s; CT Scans; Physical, Speech & Occupational Therapy (outpatient basis only) PET Scans Dialysis Durable Medical Equipment (over $500) Please refer to your SPD for complete details. Preferred Provider Organization (PPO) Your plan utilizes the Encore Health network. This network includes providers in your area. If you have any questions concerning the status of a provider in the network please feel free to contact Encore at Prescription Drug Program Your drug program is administered through KPP. You will be able to pay a copay at the time of purchase at network pharmacies. It will not be necessary to file a claim form with our office. Drug program information is included on your ID card. You may contact KPP Member Services at (800) or you can visit their website at 4

5 Eligibility & Enrollment ELIGIBILITY FOR EMPLOYEES: Employees - As required by the Patient Protection and Affordable Care Act (PPACA); all certified and contractual staff meeting the variable or full time hour minimums will be eligible for coverage. Administrators, Board Members and School Attorney will also be eligible for coverage. No person may be covered both as an Employee and a Dependent of this plan. Dependents An employee may request coverage for his/her eligible dependents. The cost of the premium for this coverage is the employee s responsibility. All dependents must meet certain criteria. All eligible dependents will commence coverage on the day the employee does if written application has been made within 30 days of the effective date. The following will be considered a dependent under this plan; Spouse Child(ren) up to age 26 The term children will include an Employee s own natural child, legally adopted child (or one for whom legal adoption proceedings have been initiated), step-child, and a child for whom the Employee or the Employee s spouse has legal guardianship. For more information, please refer to your Summary Plan Description booklet. Special Enrollment Period (CHIP) Effective April 1, 2009, when an employee or eligible dependent is covered under a Medicaid plan or states children s health insurance program (CHIP) and loses eligibility under that plan; or becomes eligible under a CHIP or Medicaid plan for premium assistance that could be used toward the cost an employer health plan, may be able to enroll within 60 days of losing coverage. Working Spouse Rule If the spouse of the Employee is employed and eligible for coverage under their own employer, benefits under this Plan will continue to be coordinated as described in the Coordination of Benefits section of this document. The spouse s plan will be primary on the spouse s claims and this Plan will pay as secondary if family coverage is elected and the appropriate premium/contribution is paid. However, if the spouse elects not to take coverage that is available through his/her employment (without regard to cost), this Plan will not provide any coverage for that spouse. The Working Spouse Rule does not apply when both husband and wife are employees of this Employer. However, no person may be both an employee and a dependent of this Plan. 5

6 Eligibility & Enrollment Waiting Period All eligible employees will commence coverage on the first day of the month following enrollment for this Employer. All coverage will commence on these dates if the Employee has agreed to make any required contributions for coverage (but not until an enrollment card has been completed and signed). Making Changes throughout the year The elections you choose during open enrollment will be in place from January 1 to December 31. Changes to these elections may require a qualifying event. In the case of a qualifying event, contact your Human Resource Department within 30 days of the event. Qualifying Events (recognized by the IRS) Birth/Adoption Death Marriage/Divorce/Legal Separation Loss of Coverage If you do not make the changes within the 30 days, you will have to wait until the next open enrollment period. PLEASE HAVE YOUR ENROLLMENT FILLED OUT AND TURNED IN NO LATER THAN NOVEMBER 18 TH. 6

7 Medical Benefits Deductible Benefits Single Family Traditional (2016- Option 1) In Out (separate) $1,000 $2,000 $2,000 $4,000 Covered Expenses In Out 80% 50% Coinsurance Limit Single Medical Family Medical In Out $4,000 $8,000 $8,000 16,000 HDHP (2016 Option 2) Embedded Deductible In Out (separate) $3,000 $6,000 $6,000 $12,000 In Out 80% 60% In Out $3,500 $7,000 $7,000 $14,000 Total Out-of-Pocket Single Rx Family Rx Single Family Emergency Care In-Network Out-of-Network $1,500 $1,500 $3,000 $3,000 In Out $6,500 $11,500 $13,000 $23,000 80% after deductible 80% after deductible Applies to deductible In Out $6,500 $13,000 $13,000 $26, % after deductible 100% after deductible Preventative Care In-Network Out-of-Network Laboratory Expenses Designated Facility All Other Prescription Drugs Primary Care Visits In-Network Out-of-Network 100% no deductible 50% after deductible In Out 100% no deductible 60% 50% after ded after ded See Prescription Drug Benefits Page 80% after deductible 50% after deductible 100% no deductible 60% after deductible In Out 100% after deductible 60% 50% after ded after ded See Prescription Drug Benefits Page 80% after deductible 60% after deductible * 5 visits per year at 100% no deductible this also applies to urgent care or walk-in clinics. Plan Status Non-Grandfathered Non-Grandfathered 7

8 Dental & Vision Benefits Dental Benefits Annual Individual Maximum (per calendar year) $1,250 Individual Deductible (per calendar year) $50.00 Covered Expenses Preventative Care All Other 100% no deductible 80% after deductible Orthodontic Benefits Covered Expenses LIFETIME Individual Maximum 60% no deductible $500 Vision Benefits- Eligibility limited to Certified and Administrative Staff Members BENEFIT DESCRIPTION IN-NETWORK OUT-OF-NETWORK PLAN LIMITATIONS Covered Expenses Examination $35.00 co-pay then 100% no deductible $35.00 co-pay then 100% no deductible Vision benefits are limited to an ANNUAL individual maximum of $400. Lenses $35.00 co-pay then 100% no deductible Frames/Contacts/Tints/ 80% no deductible Photochromics/All other covered services $35.00 co-pay then 100% no deductible 80% no deductible This plan will cover contacts or lenses in a 12 month period but not both. All services are limited to every 12 months. Except Frames are limited to every 24 months. 8

9 Prescription Drug Benefits Prescription Drug Benefit Description CVS or Walgreens All Other Pharmacies Out-of-Network Plan Limitations Prescription Drugs Retail Store (34-day supply) Generic Drugs Preferred Brand Non-Preferred Brand Retail or Mail-Order (90-day supply) Generic Drugs Preferred Brand Non-Preferred Brand Employee Pays $8 (greater of) 30% or $40 (greater of)* 50% or $60 (greater of)* $12 30% or $80 (greater of)* 50% or $120 (greater of)* Employee Pays $4 (greater of) 20% or $20 (greater of)* 30% or $50 (greater of)* $6 20% or $40 (greater of)* 30% or $60 (greater of)* No benefits are available for prescription drugs filled at out-of-network pharmacies. The Prescription Drug Program is through the approved Network listed on Employee s ID Card. * If brand name drug purchased when generic drug available and approved by physician, covered person will be responsible for the applicable brand copayment plus the difference in the cost of the generic and the brand name drug purchased. Copay may not apply to preventative prescription drugs and contraceptives. HIGH DEDUCTIBLE HEALTH PLAN (OPTION 2) PLAN PARTICIPANTS RX COPAYS ONLY APPLY AFTER THE DEDUCTIBLE HAS BEEN MET. Specialty Rx Benefits Specialty Rx (30-day supply) Generic Drugs Preferred Brand Non-Preferred Brand Option 2 Participants 10% maximum of $150 30% maximum of $250 50% maximum of $400 Copays will apply after the deductible has been met. Limited to a 30 day supply and Axium Specialty Pharmacy. Please contact KPP for assistance with the Specialty Pharmacy. Every step has been taken to insure the information in the guide is correct. Unfortunately, inaccuracies can occur, it is necessary to read the summary plan description (SPD) booklet for complete details of the benefits provided. If there is a conflict in terms of benefits described, the SPD will supersede in determining benefits paid. Again, this is only a brief description of your benefits. Please read the SPD for complete details. 9

10 Life/AD&D/LTD Benefits BASIC LIFE AD&D Employee Only: Class 1 Superintendent Class 2 Administrative Class 3 All Other Active Full-Time (except board members) Class 4 Retired Superintendent Class 5 Retired Administrative Class 6 All Other Retired Employees (except board members) Provided at no cost to the employee 3x annual base salary up to a maximum of $350,000 2x annual base salary up to a maximum of $350,000 $50,000 3x annual base salary* up to a maximum of $350,000 2x annual base salary* up to a maximum of $350,000 $50,000 *at retirement DEPENDENT LIFE Spouse Child(ren) Birth to 6 months Child(ren) Age 6 months to age 26 Employee elected and paid $5,000 $1,000 $2,500 LONG TERM DISABILITY Monthly Benefit LONG TERM DISABILITY BENEFIT Maximum Monthly Benefit Minimum Monthly Benefit Elimination Period Provided at no cost to the employee 66 2/3% of monthly earnings immediately before beginning of period of disability $7,000 $50 90 days (benefits are not payable for the elimination period) 10 Every step has been taken to insure the information in the guide is correct. Unfortunately, inaccuracies can occur, it is necessary to read the summary plan description (SPD) booklet for complete details of the benefits provided. If there is a conflict in terms of benefits described, the SPD will supersede in determining benefits paid. Again, this is only a brief description of your benefits. Please read the SPD for complete details.

11 Contributions Based on 24 pays as of January 1, 2018 Medical Benefits Option 1 Option 2 Dental Benefits $1,000 Deductible $3,000 Deductible Single $88.63 $48.04 EE + Child(ren) $ $83.72 EE + Spouse $ $91.67 Family $ $ Single $1.73 EE + Child(ren) $15.93 EE + Spouse $13.46 Family $31.54 Vision Benefits Eligibility limited to Certified and Administrative Staff Members Single $1.50 EE + Child(ren) $1.50 EE + Spouse $1.50 Family $1.50 Life/AD&D/LTD Coverage Provided at no cost to all eligible employees 11 Every step has been taken to insure the information in the guide is correct. Unfortunately, inaccuracies can occur, it is necessary to read the summary plan description (SPD) booklet for complete details of the benefits provided. If there is a conflict in terms of benefits described, the SPD will supersede in determining benefits paid. Again, this is only a brief description of your benefits. Please read the SPD for complete details.

12 Patient Protection & Affordable Care Act GROUP NAME: Richmond Schools EBT Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act (PPACA) includes health insurance market reforms that will bring immediate benefits to millions of Americans, including those who currently have coverage. Enrollment Opportunity: Lifetime Limit No Longer Applies The Lifetime Limit on the dollar value of benefits under the Richmond Schools EBT no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals may request enrollment during the l enrollment period from November 1 to November 30th. For more information, please contact your Human Resource Department. The Annual Individual Maximum will be unlimited. Enrollment Opportunity: Extension of Dependent Coverage to Age 26 Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent children ended before attainment of age 26 are eligible to enroll. Individuals may request enrollment for such children during the enrollment period of November 1 to November 30th. Enrollment will be effective on January 1. For more information, please contact your Human Resource Department. The term children will include an Employee s own natural child, legally adopted child (or one for whom legal adoption proceedings have been initiated), step-child, and a child for whom the Employee or the Employee s spouse has legal guardianship. The adult child will be eligible regardless of whether the adult child is eligible to enroll in another employer-sponsored health plan (other than a parent s plan). A plan that covers the adult child as an employee or the spouse of the employee will be primary to the plan that covers the adult child as a dependent child. When will the open enrollment period begin? This year, your employer s open enrollment period occurs November 1 to November 30 th for the January 1 effective date. This open enrollment period allows an employee to add an eligible child under the age of 26 or allows an individual to re-enroll if that person lost coverage due to meeting the lifetime limit. How long will the open enrollment period last? The enrollment period will last for 30 days. 12

13 Patient Protection & Affordable Care Act Patient Protection Disclosure: This plan does not require the designation of a primary care provider. You have the right to seek care from any primary care provider of your choice. Designation of a primary care physician is not required for children. You do not need prior authorization from the plan or Dunn and Associates Benefit Administrators, Inc. or from any other person (including a primary care physician) 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 preapproved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in primary care, pediatrics, obstetrics, or gynecology, contact Dunn and Associates Benefit Administrators at or or visit Grandfathered Plan Status: This plan is considered to be a Non-Grandfathered Plan under the PPACA. Being a grandfathered plan means that the Plan does not include certain consumer protections of the Affordable Care Act. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to Dunn and Associates Benefit Administrators at or The Plan participant may also contact the Employee Benefits Security Administration, U.S. Department of Labor at or Prohibition on Rescissions: PPACA prohibits a group health plan from rescinding health coverage except in the case of fraud or intentional misrepresentation of a material fact. Prohibition on Preexisting Condition Exclusions: PPACA prohibits group health plans from denying coverage based on an applicant s preexisting condition. We appreciate the opportunity to serve as your Third Party Administrator and are committed to keeping you informed of any changes that might affect your plan. If you have any additional questions or are unclear how this new law will affect your plan, please do not hesitate to contact us. 13

14 Important Notice About Your Prescription Drug Coverage and Medicare Traditional Plan Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with your employer and prescription drug coverage available for people with Medicare. It also explains the options you have under Medicare prescription drug coverage and can help you decide whether or not you want to enroll. At the end of this notice is information about where you can get help to make decisions about your prescription drug coverage. Medicare prescription drug coverage became available in 2007 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug coverage. All Medicare prescription 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. Your employer has determined that the prescription drug coverage they offer is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage. Because your existing coverage is on average at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare prescription drug coverage. Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from November 15 th through December 31 st. Beneficiaries leaving employer/union coverage may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan. You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. If you do decide to enroll in a Medicare prescription drug plan and drop your employer s prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. Please contact us for more information about what happens to your coverage if you enroll in a Medicare prescription drug plan. You should also know that if you drop or lose the coverage with your employer and don t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. If you go 63 days or longer without prescription drug coverage that s at least as good as Medicare s prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than what many other people pay. You ll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to enroll. For more information about this notice or your current prescription drug coverage Contact our office for further information. NOTE: You will receive this notice annually and at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if the coverage through your employer changes. You also may request a copy. 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 prescription drug plans. For more information about Medicare prescription drug plans: Visit Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help, Call MEDICARE ( ). TTY users should call For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at or you call them at (TTY ). Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount. Date: November 2017 Name of Entity/Sender: Richmond Community Schools Contact--Position/Office: Jennifer O Brien, HR Address: 300 Hub Etchison Pkwy Richmond, IN Phone Number: (765)

15 Important Notice About Your Prescription Drug Coverage and Medicare HDHP Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with your employer 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. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are three important things you need to know about your current coverage and Medicare s prescription drug coverage: 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. Your employer has determined that the prescription drug coverage they offer is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage is considered Non-Creditable Coverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage from the Employer. This also is important because it may mean that you may pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible. You can keep your current coverage with your employer. However, because your coverage is non-creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully - it explains your options. 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 decide to drop your current coverage your employer, since it is employer/union sponsored group coverage, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan; however you also may pay a higher premium (a penalty) because you did not have creditable coverage. Since you are losing creditable prescription drug coverage under the employer, you are also eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? Since the coverage under your employer is not creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn t join, if you go 63 continuous days or longer without prescription drug coverage that s creditable, 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 (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. 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 coverage may or may not be affected. If you drop your current drug plan and enroll in Medicare drug coverage you may enroll back into the benefit plan during the open enrollment period. For More Information about this Notice Or Your Current Prescription Drug Coverage contact your Employer. 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 your employer 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 ). Date: November 2017 Name of Entity/Sender: Richmond Community Schools Contact--Position/Office: Jennifer O Brien, HR Address: 300 Hub Etchison Pkwy Richmond, IN Phone Number: (765)

16 Women s Health & Cancer Rights Act (WHCRA) The Women s Health and Cancer Rights Act (WHCRA) was signed into law on October 21, The law requires that Employees are notified of the Maternity and Mastectomy benefits it encompasses periodically. Maternity Benefits (Precertification) The Department of Labor (DOL) has issued an interim regulation that modifies the Newborns and Mothers Health Protection Act of The Newborns and Mothers Health Protection Act generally prohibits health insurance issuers and group health plans from restricting benefits for hospitalization 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. The DOL s interim regulation further clarifies (or modifies) this act by stating that Federal law generally does NOT prohibit the mother or newborn s attending health provider from discharging the mother or her newborn earlier than 48 hours after vaginal delivery or 96 hours after cesarean section when the provider has consulted with the mother first. Mastectomy Surgery (Related Services Covered) The Women s Health and Cancer Rights Act of 1998, enacted as part of the Omnibus Budget Bill, requires that group health plans providing coverage for a mastectomy to also cover additional related charges. We are pleased to say that your plan does provide coverage for mastectomies; therefore, the following related services are now also covered under your plan: Breast reconstruction of a surgically removed breast Surgery and reconstruction of the other breast to produce a symmetrical appearance Prostheses and treatment for physical complications from all stages of mastectomy, including lymphedemas Applicable copayments and deductibles apply to these services as indicated in your Summary Plan Description. 16

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19 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 July 31, Contact your State for more information on eligibility To see if any other states have added a premium assistance program since July 31, 2016, 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 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 INDIANA Medicaid Healthy Indiana Plan for low-income adults Website: Phone: All other Medicaid Website: Phone

20 HHS Non-Discrimination Notice The U.S. Department of Health and Human Services (HHS) complies with applicable Federal civil rights laws and does not discriminate on the base of race, color, national origin, age, disability, or sex. HHS does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. HHS provides free aids and services to people with disabilities to communicate effectively with us such as; Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English such as; Qualified interpreters Information written in other languages If you need these services, contact HHS at 1 (877) If you believe HHS has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights compliant portal, by mail or phone. US Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC (800) or 1 (800) (TDD) Complaint forms are also available at 20

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