Special Enrollment Rights
If you are declining enrollment for yourself or your covered dependents (including your spouse) because of other 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 the employer stops contributing towards your or your dependent’s other coverage). However, you must request enrollment within 30 days after you or your other dependents’ coverage ends.
You may also be able to enroll yourself or your covered dependents in the future if you or your dependents lose health coverage under Medicaid or your state’s Children’s Health Insurance Program (CHIP), or become eligible for state premium assistance for purchasing coverage under a group health plan, provided that you request enrollment within 60 days after that coverage ends.
In addition, if you have a new dependent as a result of marriage, birth, adoption or placement of adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after marriage or 60 days after birth, adoption or placement for adoption. To request special enrollment or obtain more information, contact your Human Resources Department. Refer to your benefit booklet for details.
Non-Network Costs
The amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specific service rendered. Although your plan stipulates an out-of-network maximum for out-of-pocket services, please note that the maximum allowed amount for an eligible procedure may not equal the amount charged by your out-of-network provider. Your out-of-network provider may bill you for the difference between the amount charged and the maximum allowed amount. This is called balance billing and the amount billed to you can be substantial. The out-of-pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defined by your plan. The maximum reimbursable amount for non-network providers can be based on a number of schedules such as percentage or reasonable and customary or a percentage of Medicare. Contact your claims payer or insurer for more information. The plan document (benefit booklet) is the controlling document, and the benefit highlights contained in this guide do not include all of the terms, coverage, exclusions, limitations and conditional of the actual plan language.
Women’s Health and Cancer Rights Act
The Women’s Health and Cancer Rights Act of 1998 requires group health plans that provide medical and surgical coverage for mastectomies also provide coverage for reconstructive surgery following such mastectomies in a manner determined in consultation with the attending physician and the patient.
Coverage must include:
- All stages of reconstruction of the breast on which the mastectomy has been performed,
- Surgery and reconstruction of the other breast to produce a symmetrical appearance, and
- Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedema.
Benefits for the above coverage are payable on the same basis as any other physical condition covered under the plan, including any applicable deductible and/or copays and coinsurance amounts.
HIPAA Notice of Privacy Practices Reminder
HIPAA requires the employer to notify its employees that a privacy notice is available from the Human Resources Department. To request a copy of the employer’s Privacy Notice or for additional information, please contact Human Resources.
Newborns’ and Mothers’ Health Protection Act of 1996
The Newborns’ Act and its regulations provide that any group health plans and health insurance issuers general- ly 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 the newborn earlier than 48 hours (96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authoriza- tion from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
The Newborns’ Act and its regulations, prohibit incentives (either positive or negative) that could encourage less than the minimum protections under the Act as described above.
A mother cannot be encouraged to accept less than the minimum protections available to her under the Newborns’ Act and an attending provider cannot be induced to discharge a mother or newborn earlier than 48 or 96 hours after delivery.
COBRA
Federal COBRA is a U.S. law that applies to employers who employ 20 or more individuals and sponsor a group health plan. Under Federal COBRA, you may be eligible to continue your same group health insurance for up to 18 months if your job ends or your hours are reduced. You are responsible for COBRA premium payments.
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 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, you may contact the Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) in your state to find out if premium assistance is available.
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, please contact the Department of Labor at www.askebsa.dol.gov or call 1.866.444.EBSA (3272).
To see if any of the additional states offer a premium assistance program, or for more information on special enrollment rights, you can contact either:
About the Information on this Site
The information on this site is presented for illustrative purposes. The text on the site was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of any discrepancy between this guide and the formal plan documents, the Benefit Booklet will always prevail on issues concerning benefits available, and the Summary Plan Description shall prevail on issues concerning eligibility and enrollment. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996.