Annual Notices - SDRMA 0 2015-01-01 Annual Notices 2015
Notice of Availability of HIPAA Privacy Notice The federal Health Insurance Portability and Accountab ility Act (HIPAA) require s that we periodically remind you of your right to receive a copy of t he Insurance Carriers’ HIPAA Privacy Notices. You can request copies of the Privacy Notices by contac ting the Human Resources Department or by contacting the insurance carriers directly. The Women’s Health and Cancer Rights Act The Women’s Health and Cancer Rights Act (WHCR A) requires employer groups to notify participants and beneficiaries of the group health plan, of their rights to mastectomy benefits under the plan. Participants and beneficiaries have rights for cover age to be provided in a manner determined in consultation with the attending Physician for: ● All stages of reconstruction of the breast on which the mastectomy was performed; ● Surgery and reconstruction of the other brea st to produce a symmetrical appearance; ● Prostheses; and Treatment of physical complicati ons of the mastectomy, including lymphedema. These benefits are subject to the same deductibl e and co-payments applicable to other medical and surgical procedures provided under this plan. You can contact your health plan’s Member Services for more information. Newborns’ and Mothers’ Health Protection Act Notice 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 mo ther or newborn child to less than 48 hours following a vagina l delivery, or less than 96 h ours 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 ne wborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuer s may not, under Federal law, require that a provider obtain authorization from th e plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hour s). If you would like more information on maternity benefits, call your plan administrator. 1 | PAGE REQUIRED FEDERAL NOTICES
HIPAA Notice of Special Enrollment Ri ghts for Medical/Health Plan Coverage If you decline enrollment in a CSAC Excess Insuranc e Authority’s (EIA) health plan for you or your dependents (including your spouse) because of other health insur ance or group health plan coverage, you or your dependents may be able to enroll in a CSAC Excess Insurance Authority’s (EIA) health plan without waiting for the next open enrollment period if you: ● Lose other health insurance or group health plan coverage. You must request enrollment within [30/31] days after the loss of other coverage. ● Gain a new dependent as a result of marriage, birth, adoption, or placement for adoption. You must request [medical plan OR health plan] enr ollment within [30/31] days after the marriage, birth, adoption, or placement for adoption. ● Lose Medicaid or Children’s He alth Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical plan enrollment within 60 days after the loss of such coverage. If you request a change due to a s pecial enrollment event within th e [30/31] day timeframe, coverage will be effective the date of birth, adoption or placement for adoption. For all other events, coverage will be effective the first of the month following your reques t for enrollment. In addition, you may enroll in CSAC Excess Insurance Authority’s (EIA) medical plan if yo u become eligible for a state premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days after you gain eligibility for medical plan coverage. If you request this change, coverage will be effective the first of the month fo llowing your request for enrollment. Specific restrictions may apply, depending on federal and state law. Note: If your dependent becomes eligible for a special enrollment ri ghts, you may ad d the dependent to your current coverage or change to another health plan. 2 | PAGE REQUIRED FEDERAL NOTICES
3 | PAGE Rules for Benefit Chan ges During the Year Other than during annual open enrollment, you may only make changes to your benefit elections if you experience a qualified status change or qualify for a “special enrollment”. If yo u qualify for a mid-year benefit change, y ou may be required to subm it proof of the change or evidence of prior coverage. Qualified Status Changes include: Change in legal marital status , including marriage, divorce, l egal separation, annulment, and death of a spouse Change in number of dependents , including birth, adoption, plac ement for adoption, or death of a dependent child Change in employment status that affects benefit eligibility , including the start or termination of employment by you, your s pouse, or your dependent child Change in work schedule , including an increase or decrease in hours of employ ment by you, your spouse, or your dependent child, including a switch between part-time and full-time employment that affect s eligibility for benefits Change in a child's dependent status , either newly satisfying the requirements for dependent child status or ceasing to satisfy them Change in place of residence or worksite , including a change that affe cts the accessibility of network providers Change in your health coverage or your spouse's coverage attributable to your spouse's employment Change in an individual's elig ibility for Medicare or Medicaid A court order resulting from a divorce, legal separation, annulment, or change in legal custody (including a Qualified Medical Child Support Order) requiring coverage for your child. An event that is a “special enrollment” unde r the Health Insurance Portability and Accountability Act (HIPAA) including acquisition of a new dependent by marriage, birth or adoption, or loss of coverage under another health insurance plan . An event that is allowed under the Children 's Health Insurance Program (CHIP) Reauthorization Act. Under provisions of the Act, employees have 60 days after the following events to reques t enrollment: Employee or dependent loses eligib ility for Medicaid (known as Medi-Cal in CA) or CHIP (known as Healthy Families in CA). Employee or dependent becomes e ligible to participate in a premium assistance program under Medicaid or CHIP. Two rules apply to making changes to your benefits during the year: Any changes you make must be consiste nt with the change in status, AND You must make the changes within 30 days of the date the event (marriage, birth, etc.) occurs (unless otherwise noted above). REQUIRED FEDERAL NOTICES
Date: Name of Entity: Contact: Address: Phone Number: __________________________ __________________________ __________________________ __________________________ __________________________ REQUIRED FEDERAL NOTICES
ALABAMA – Medicaid COLORADO – Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-855-692-5447 Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 ALASKA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA – CHIP FLORIDA – Medicaid Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437 Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 GEORGIA – Medicaid Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 Premium Assistance Under Medicaid and the Chil dren’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 a ssistance program that c an help pay for coverage, using funds from their M edicaid or CHIP progr ams. If you or your ch ildren aren’t eligible for Medicaid or CHIP, you won’t be eligible for t hese premium assistance pr ograms but you may be able to buy individual insurance coverage through th e Health Insurance Mark etplace. 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 a ssistance is available. If you or your dependents are NOT curr ently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be elig ible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help y ou pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under M edicaid or CHIP, as well as eligible under your employ er plan, your employer mu st allow you to enroll in your employer plan if you aren’t already enrolled. Th is is called a “special enrollment ” opportunity, and you must request coverage within 60 days of being det ermined eligible for premium a ssistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-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, 2014. Contact your State for more information on eligibility – 4 | PAGE Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low Cost Health Coverage to Children and Families
IDAHO – Medicaid MONTANA – Medicaid Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssistance/tabid/1510/Default.aspx Medicaid Phone: 1-800-926-2588 Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Phone: 1-800-694-3084 INDIANA – Medicaid NEBRASKA – Medicaid Website: http://www.in.gov/fssa Phone: 1-800-889-9949 Website: www.ACCESSNebraska.ne.gov Phone: 1-800-383-4278 IOWA – Medicaid NEVADA – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 Medicaid Website: http://dwss.nv.gov / Medicaid Phone: 1-800-992-0900 KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447 Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 MAINE – Medicaid Website: http://www.maine.gov/dhhs/o fi/public-assistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741 MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120 Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 MINNESOTA – Medicaid NORTH CAROLINA – Medicaid Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 1-800-657-3629 Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 5 | PAGE Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low Cost Health Coverage to Children and Families
OREGON – Medicaid VERMONT – Medicaid Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075 Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462 Medicaid Website: http://www.dmas.virginia.gov/rcp-HIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/ CHIP Phone: 1-866-873-2647 RHODE ISLAND – Medicaid WASHINGTON – Medicaid Website: www.ohhs.ri.gov Phone: 401-462-5300 Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspx Phone: 1-800-562-3022 ext. 15473 SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059 Website: http://www.badgercareplus.org/pubs/p-10095.htm Phone: 1-800-362-3002 TEXAS – Medicaid WYOMING – Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531 To see if any other states have added a premium assistance program since J anuary 31, 2014, or for more information on special enro llment rights, contact either: U.S. Department of Labor U.S. Depar tment of Health and Human Services Employee Benefits Security Administration C enters for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 OMB Control Number 1210-0137 (expires 10/31/2016) OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://health.utah.gov/upp Phone: 1-866-435-7414 6 | PAGE Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low Cost Health Coverage to Children and Families