BENEFITS GUIDE
An overview of the wide array of benefits provided by MOTHER , to help you enjoy increased well-being and financial security
TABLE OF CONTENTS
▪
Introduction
3
▪ Overview of Benefits Programs
4
▪
Medical Benefits
6
▪ Health Savings Account (HSA)
11
▪
Dental Benefits
15
▪
Vision Benefits
17
▪
Contributions
19
▪ Flexible Spending Account (FSA)
22
▪
Commuter
23
▪ Employer Assistance Program (EAP)
24
▪
Pet Insurance
25
▪
One Medical
27
▪
Benefit Bump
28
▪
Benefit Hub
29
▪
How to Enroll
30
▪
Legal Notices
32
▪
Legal Notices - COBRA
42
▪
Legal Notices - FMLA
76
▪
Contact Page
49
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MOTHER BENEFITS GUIDE
TABLE OF CONTENTS I
INTRO & OVERVIEW
OVERVIEW OF BENEFITS
CHANGES AND QUALIFYING EVENTS
WHEN COVERAGE BEGINS AND ENDS
Your coverage under the benefits plans will end if you no longer meet the eligibility requirements, your contributions are discontinued or the Group Insurance Policy is terminated.
QUALIFYING EVENTS
• Eligible employees may enroll or make changes to their benefits elections during the annual open enrollment period. As with most benefits, once you elect an option you are bound to that choice for the entire plan year unless you experience a “Qualifying Event” . These may include, but are not limited to: • Changes in employment status • Changes in legal marital status • Changes in number of dependents • Taking an unpaid leave of absence • Dependent satisfies or ceases to satisfy eligibility requirement • Family Medical Leave Act (FMLA) leave. • A COBRA-qualifying event • Entitlement to Medicare or Medicaid • A change in the place of residence of the employee, resulting in the current carrier not being available • All Employees shall be eligible on the first day of the month following date of employment.
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MOTHER BENEFITS GUIDE
OVERVIEW I
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OVERVIEW OF BENEFITS
Mother provides an array of benefits that can help you enjoy increased well-being, deal with an unexpected illness or accident, build and protect your financial security, balance your personal and professional life and meet everyday needs. These benefits are affordable, comprehensive and competitive. The table below summarizes the benefits available to eligible staff and their dependents. These benefits are described in greater detail in this booklet.
Coverage
Carrier
BENEFITS AT-A-GLANCE
Medical Dental Vision
Coverage
Carrier
Flexible Spending Account (FSA)
Commuter
Employee Assistance Program (EAP)
Pet Insurance
Healthcare App
Benefit Bump
Benefit Hub
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OVERVIEW I
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MEDICAL
MEDICAL PLAN 1 – PPO Plan
SUMMARY OF COVERAGE
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MEDICAL PLAN
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MEDICAL PLAN 2 – EPO Plan
SUMMARY OF COVERAGE
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MEDICAL PLAN
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MEDICAL PLAN 3 – Base EPO Plan
SUMMARY OF COVERAGE
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MEDICAL PLAN
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MEDICAL PLAN 4 – HSA Plan
SUMMARY OF COVERAGE
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MEDICAL PLAN
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HEALTH SAVINGS ACCOUNT (HSA)
MOTHER IS OFFERING A HEALTH SAVINGS ACCOUNT (HSA) FOR MEDICAL PLAN 4 ONLY. THIS IS HOW AN HSA WORKS :
A health savings account (HSA) is a health care account and savings account in one. The main purpose of this account is to offset the cost of a qualifying high deductible health plan (HDHP) and provide savings for your out-of-pocket eligible health care expenses – those you and your tax dependents may have now, in the future, and during your retirement.
This is a “portable” account. You own your HSA! It’s included in your employee benefits package, but after you set up your account, it’s yours to keep, even if you change jobs or retire.
Once your HSA is established, money is contributed to your account by you, MOTHER or friends and family, and you can then use your HSA dollars tax-free to pay for eligible health care expenses. You save money on expenses you’re already paying for, like doctors’ office visits, prescription drugs, and much more. Best of all, you decide how and when to use your HSA dollars.
WHY IS IT A GOOD IDEA TO HAVE AN HSA?
HSAs benefit everyone who is eligible to have this account – single individuals, families, and soon- to-be retirees. You save money on taxes in three ways:
Tax-free deposits The money you contribute to your HSA isn’t taxed (up to the IRS annual limit)
Tax-free earnings Your interest and any investment earnings grow tax-free
Tax-free withdrawals Money used toward eligible health care expenses isn’t taxed – now or in the future
HSA funds roll over from year to year and accumulate in your account. There is no “use -it-or-lose- it” rule with HSAs, and you decide how and when to use your HSA funds, which can be used for eligible expenses you have now, in the future, or during retirement. And when you have a certain balance in your HSA, investment opportunities are available. Setting aside pre-tax dollars into your HSA you pay fewer taxes and increase your take-home pay by your tax savings. You save money on eligible expenses that you are paying for out of your pocket. The amount you save depends on your tax bracket. For example, if you are in the 30 percent tax bracket, you can save $30 on every $100 spent on eligible health care expenses.
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HSA I
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HEALTH SAVINGS ACCOUNT (HSA)
Mother will make an employer contribution (employees will need to adjust their contribution
Your money can earn interest and you may choose from investment options
Contributions from payroll to the HSA are voluntary and made pre-tax
An individually owned bank account (you own it)
by IRS limits accordingly)
A Health Savings Account (HSA) allows you to reduce your taxable income and save for eligible healthcare expenses
IRS limits the total amount you can deposit annually $4,150 for employee- only coverage • $8,300 for those covering dependents on the HDHP
Unused funds roll over from year to year, no “use -it-or-lose- it”
Employer HSA Contribution
Monthly**
Coverage Tier Employee Only
$13 $21
Employee + Spouse / Domestic Partner
Employee + Child(ren)
$23 $32
Family
HSA contributions by Mother will be made on semi-monthly basis
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HSA I
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MEDICAL PLAN
KEY TERMS TO REMEMBER
ANNUAL DEDUCTIBLE
OUT-OF POCKET MAXIMUM
The amount you have to pay each year before the plan starts paying a portion of medical expenses. All family members’ expenses that count toward a health plan deductible accumulate together in the aggregate; however, each person also has a limit on their own individual accumulated expenses (the amount varies by plan).
This is the total amount you can pay out of pocket each calendar year before the plan pays 100 percent of covered expenses for the rest of the calendar year. Most expenses that meet provider network requirements count toward the annual out- of-pocket maximum, including expenses paid to the annual deductible*, copays and coinsurance *Except for Grandfathered medical plans
COPAYS AND COINSURANCE
PLAN TYPES
• EPO/PPO – A network of doctors, hospitals, and other health care providers • HMO – A network that requires you to select a Primary Care Physician (PCP) who coordinates your health care • POS – Combines aspects of a PPO and HMO • HDHP – A plan that has higher annual deductibles in exchange for lower premiums.
These expenses are your share of cost paid for covered health care services. Copays are a fixed dollar amount, and are usually due at the time you receive care. Coinsurance is your share of the allowed amount charged for a service, and is generally billed to you after the health insurance company reconciles the bill with the providers.
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MEDICAL PLAN I
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MEDICAL PLAN
The US Preventive Services Task Force maintains a regular list of recommended services that all Affordable Care Act (i.e. Health Care Reform) compliant insurance plans should cover at 100% for in-network providers. Below is a list of common services that are included in the plans offered this year: immunizations. Through the plans offered by Mother, all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived. WHICH PREVENTIVE CARE SERVICES ARE COVERED? Understanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and
“AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE”
• Routine Physical Exam • Well Baby and Child Care • Well Woman Visits • Immunizations • Routine Bone Density Test • Routine Breast Exam • Routine Gynecological Exam • Screening for Gestational Diabetes • Obesity Screening and Counseling • Routine Digital Rectal Exam • Routine Colonoscopy
• Routine Colorectal Cancer Screening • Routine Prostate Test
• Routine Lab Procedures • Routine Mammograms • Routine Pap Smear • Smoking Cessation Programs
• Health Education/Counseling Services • Health Counseling for STDs and HIV • Testing for HPV and HIV • Screening and Counseling for Domestic Violence
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MOTHER BENEFITS GUIDE
MEDICAL PLAN I
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DENTAL
DENTAL PLANS
SUMMARY OF COVERAGE
Plan Highlights
DPPO (In-Network)
OUT-OF-NETWORK
Calendar Year Deductible
$50 per person $150 per family
Calendar Year Maximum Benefit
$1,500 Maximum combined for in and out of network
Diagnostic & Preventive Care Services Oral exams, x-rays, other diagnostic services, routine preventive services
100% (deductible waived)
100% (deductible waived)
Basic Services Filings, simple extractions, endodontics, oral surgery
80%
80%
Major Services Periodontics, dentures, crowns & fixed bridges
50%
50%
Orthodontia Services (to age 19)
50% up to a lifetime maximum of $1,5000
90 th Percentile of Allowed Charges
Dental Plan Reimbursement Level
Based on Contracted Fees
Out-of-Network services are paid based on allowable charges. Member may be responsible for paying the balance of the billed amount above that rate (commonly known as “balance billing”)
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DENTAL PLAN I
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VISION
VISION PLANS
SUMMARY OF COVERAGE
Out of Network Reimbursement
Key Features
In Network Cost
Annual Well Vision Eye Exam Once Per 12 Months
$15 copay
Up to $45 Allowance
Lenses Single Vision Lined Bifocal Lined Trifocal Once Per 12 Months
Up to $32 Allowance Up to $55 Allowance Up to $65 Allowance
$30 Copay for All
Frame Retail Once Per 24 Months
100% up to $130 Retail Allowance + 20% off the Balance
Up to $71 Allowance
Contacts ( in lieu of glasses) Elective Once Per 12 Months
$100% up to a $110 Retail Allowance
Up to $98 Allowance
Contacts ( in lieu of glasses) Therapeutic Once Per 12 Months
Up to $210 Allowance
$0
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VISION PLAN I
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CONTRIBUTIONS
EMPLOYEE CONTRIBUTIONS
MONTHLY EMPLOYEE CONTRIBUTIONS
Monthly Contributions
Medical Plan 1 PPO Plan
Medical Plan 2 EPO Plan
Medical Plan 3 Base EPO Plan
Medical Plan 4 HSA Plan
Coverage Tier
Employee Only
$211.05
$157.67
No Cost
No Cost
Employee + Spouse
$1,055.24
$630.67
$579.71
$609.01
Employee + Child(ren)
$339.78
$253.84
$233.33
$222.26
Family
$914.89
$759.43
$698.06
$664.94
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CONTRIBUTIONS I
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EMPLOYEE CONTRIBUTIONS
MONTHLY EMPLOYEE CONTRIBUTIONS
Monthly Contributions
Coverage Tier
Dental
Vision
Employee Only
No Cost
No Cost
Employee + Spouse
$16.06
No Cost
Employee + Child(ren)
$22.14
No Cost
Family
$38.20
No Cost
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CONTRIBUTIONS I
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FLEXIBLE SPENDING ACCOUNT (FSA)
Mother is offering a Flexible Spending Account (FSA) for 2024. This is how an FSA works:
• You set aside money for your FSA from your paycheck before taxes are taken out. ($3,200 Max) • Then use your pre-tax FSA funds throughout the plan year to pay for eligible health care or dependent care expenses. • You save money on expenses you’re already paying for.
Healthcare FSA Grace Period Extension – Allows employees to incur dates of service up to 12 months after the end of the current plan year, 12/31/23 with a deadline of 3/15/24 to file those eligible claims
DEPENDENT CARE FSA ELIGIBLE EXPENSES
HEALTH FSA ELIGIBLE EXPENSES
• Medical expenses: co-pays, co- insurance, and deductibles • Dental expenses: exams, cleanings, X- rays, and braces • Vision expenses: exams, contact lenses and supplies, eyeglasses, and laser eye surgery • Professional services: physical therapy,
• Care for your child who is under age 13 • Before and after-school care • Baby sitting and nanny expenses • Day care, nursery school, and preschool • Summer day camp • Care for a relative who is physically or mentally incapable of self-care and lives in your home
chiropractor, and acupuncture • Prescription drugs and insulin
• Over-the-counter health care items: bandages, pregnancy test kits, blood pressure monitors, etc.
Refer to your FSA documentation for more information.
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FSA I
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COMMUTER BENEFITS
• You set aside money for your transportation costs from your paycheck before taxes up to $315 for transit and $315 for parking expenses per month.
• You save money on expenses you’re already paying for
• Enrollment can be done by signing up over at HealthEquity:
• https://healthequity.com/learn/commuter
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COMMUTER BENEFITS I
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EMPLOYEE ASSISTANCE PROGRAM
Telus Health (Formerly Lifeworks) is a completely confidential program that is available to help you and your whole family. Resources are available for:
Employees have access to:
• Up to five in-person sessions with a counselor completely free • 24-hour assistance from professional consultants available by phone, app, and LifeWorks.com • Referrals to local services and national resources for financial & legal services
Access to all online resources through: www.lifeworks.com/**
Username: mother
Password: lifeworks
**Lifeworks site address will redirect to Telus Health with access to the same benefits
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EMPLOYEE ASSISTANCE PROGRAM I
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PET INSURANCE
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MOTHER BENEFITS GUIDE
PET INSURANCE I
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PET INSURANCE
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MOTHER BENEFITS GUIDE
PET INSURANCE I
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ONE MEDICAL
Additional fees may apply to individual employees for certain ‘Mindset’ services, the additional cost is the employee’s responsibility if incurred.
Individual employees (not their dependents) are able to sign up for One Medical on their website for $199 per person per year.
Mother will then issue a reimbursement to employees for the cost of this services
To sign up visit: https://app.onemedical.com/register?service_area_id=3
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ONE MEDICAL
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BENEFIT BUMP
Benefit Bump: a benefit guidance for the many paths to parenthood (i.e. adoption, fertility-assisted paths, or surrogacy) not just pregnancy, but for everyone. "
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BENEFIT BUMP I
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BENEFIT HUB
https://mother.benefithub.com /
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BENEFIT HUB
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HOW TO ENROLL
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HOW TO ENROLL I
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HOW TO ENROLL
• For your Medical, Dental, Vision, & Healthcare FSA, access UKG: Click UKG
• One Medical- An individual employee can enroll by going to: Click Here
•
Benefit Bump - Please reach out to your PeopleTeam for additional enrollment information
•
Pet Insurance Options: - Discount Total Pet Program will require all employees to complete a paper enrollment form. Please reach out to the people team for more info.
- Wishbone Pet Insurance- Cost varies by your pet and their age. To access a proposal please visit- www.wishboneinsurance.com/mother
• WageWorks (Transit): www.wageworks.com
•
LifeWorks (Now Telus Health) www.lifeworks.com Username- mother Password- lifeworks 800.433.7916
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HOW TO ENROLL I
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LEGAL NOTICES
LEGAL NOTICES
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that addresses the privacy and security of certain individually identifiable health information, called protected health information (or PHI). You have certain rights with respect to your PHI, including a right to see or get a copy of your health and claims records and other health information maintained by a health plan or carrier. For a copy of the Notice of Privacy Practices, describing how your PHI may be used and disclosed and how you get access to the information, contact Human Resources.
Women’s Health and Cancer Rights Act Enrollment Notice
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Woman’s Health and Cance r 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:
1. All stages of reconstruction of the breast on which mastectomy was performed. 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses. 3. Treatment of physical complications of the mastectomy, including lymphedema.
These will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this benefits plan. If you would like more information on WHCRA benefits, call your plan administrator.
Newborns’ and Mothers’ Health Protection Act Disclosure
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 the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Patient Protection Notice
Your carrier generally may require the designation of a primary care provider. You have the right to designate any primary care provider who participates in your network and who is available to accept you or your family members. Until you make this designation, your carrier may designate one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact the carrier. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from your carrier 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 your 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 the carrier.
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LEGAL NOTICES I
LEGAL NOTICES
HIPAA Special Enrollment 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 en rollment within 30 days after your 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. If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or b ecome eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy. To request special enrollment or to obtain more information about the plan's special enrollment provisions, contact the plan administrator.
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LEGAL NOTICES I
LEGAL NOTICES
Premium Assistance Under Medicaid and t he Children’s Health Insurance Program (CH IP)
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 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 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” o pportunity, 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 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 October 15, 2021. Contact your State for more information on eligibility –
COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program HIBI Customer Service: 1-855-692-6442
ALABAMA – Medicaid
Website: http://myalhipp.com/ Phone: 1-855-692-5447
ALASKA – Medicaid
FLORIDA – Medicaid
The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp /index.html Phone: 1-877-357-3268
ARKANSAS – Medicaid
GEORGIA – Medicaid
Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)
Website: https://medicaid.georgia.gov/health-insurance-premium- payment-program-hipp Phone: 678-564-1162 ext 2131
CALIFORNIA – Medicaid
INDIANA – Medicaid
Website: Health Insurance Premium Payment (HIPP) Program
Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584
http://dhcs.ca.gov/hipp Phone: 916-445-8322 Email: hipp@dhcs.ca.gov
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LEGAL NOTICES I
LEGAL NOTICES
IOWA – Medicaid and CHIP (Hawki)
MONTANA – Medicaid
Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to- z/hipp HIPP Phone: 1-888-346-9562
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
KANSAS – Medicaid
NEBRASKA – Medicaid
Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884
Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178
KENTUCKY – Medicaid
NEVADA – Medicaid
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov
Medicaid Website: http://dhcfp.nv.gov/ Medicaid Phone: 1-800-992-0900
LOUISIANA – Medicaid
NEW HAMPSHIRE – Medicaid
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218
MAINE – Medicaid
NEW JERSEY – Medicaid and CHIP
Enrollment Website: https://www.maine.gov/dhhs/ofi/applications- forms Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms
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
Phone: -800-977-6740. TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
NEW YORK – Medicaid
Website: https://www.mass.gov/info-details/masshealth-premium- assistance-pa Phone: 1-800-862-4840
Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
MINNESOTA – Medicaid
NORTH CAROLINA – Medicaid
Website: https://mn.gov/dhs/people-we-serve/children-and-families/health- care/health-care-programs/programs-and-services/other- insurance.jsp Phone: 1-800-657-3739
Website: https://medicaid.ncdhhs.gov/ 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: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP
UTAH – Medicaid and CHIP
Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669
OREGON – Medicaid
VERMONT – Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
PENNSYLVANIA – Medicaid
VIRGINIA – Medicaid and CHIP
Website: https://www.dhs.pa.gov/providers/Pages/Medical/HIPP- Program.aspx Phone: 1-800-692-7462
Website: http://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282
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LEGAL NOTICES
RHODE ISLAND – Medicaid
WASHINGTON – Medicaid
Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022
SOUTH CAROLINA – Medicaid
WEST VIRGINIA – Medicaid
Website: http://www.scdhhs.gov Phone: 1-888-549-0820
Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid
WISCONSIN – Medicaid and CHIP
Website: http://dss.sd.gov Phone: 1-888-828-0059
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002
TEXAS – Medicaid
WYOMING – Medicaid
Website: http://gethipptexas.com/ Phone: 1-800-440-0493
Website: https://health.wyo.gov/healthcarefin/medicaid/programs- and-eligibility/ Phone: 1-800-251-1269
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LEGAL NOTICES I
LEGAL NOTICES
To see if any other states have added a premium assistance program since October 15, 2021, or for more information on special enrollment rights, contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (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. 3507. 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. 3512. The public reporting burden for this collection of information is estimated to average approximately four 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, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210- 0137.
OMB Control Number 1210-0137 (expires 1/31/2024)
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Genetic Information Nondiscrimination Act (GINA) Disclosures Genetic Information Nondiscrimination Act of 2008
The Genetic Information Nondiscrimination Act of 2008 (“GINA”) protects employees against discrimination based on their
genetic information. Unless otherwise permitted, your Employer may not request or require any genetic information from you
or your family members.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II
from requesting or requiring genetic information of an individual or family member of the individual, except as specifically
allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to
this request for medical information. “Genetic information,” as defined by GINA, includes an individual’s family medical hist ory,
the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member
sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family
member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
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USERRA Notice Your Rights Under USERRA A. The Uniformed Services Employment and Reemployment Rights Act
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services. B. Reemployment Rights You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed service and: • You ensure that your employer receives advance written or verbal notice of your service; • You have five years or less of cumulative service in the uniformed services while with that particular employer; • You return to work or apply for reemployment in a timely manner after conclusion of service; and • You have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been absent due to military service or, in some cases, a comparable job. C. Right to Be Free from Discrimination and Retaliation If you: • Are a past or present member of the uniformed service; • Have applied for membership in the uniformed service; or • Are obligated to serve in the uniformed service; then an employer may not deny you o Initial employment; o Reemployment; o Retention in employment; o Promotion; or o Any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection. If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. • Even if you do not elect to continue coverage during your military service, you have the right to be reinstated in your employer's health plan when you are reemployed, generally without any waiting periods or exclusions (e.g., pre-existing condition exclusions) except for service-connected illnesses or injuries. D. Health Insurance Protection •
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E. Enforcement •
The U.S. Department of Labor, Veterans' Employment and Training Service (VETS) is authorized to investigate and resolve complaints of USERRA violations. For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-DOL or visit its Web site at http://www.dol.gov/vets. An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm. • If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for representation. • You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA. The rights listed here may vary depending on the circumstances. The text of this notice was prepared by VETS, and may be viewed on the Internet at this address: http://www.dol.gov/vets/programs/userra/poster.htm. Federal law requires employers to notify employees of their rights under USERRA, and employers may meet this requirement by displaying the text of this notice where they customarily place notices for employees. U.S. Department of Labor, Veterans' Employment and Training Service, 1-866-487-2365.
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COBRA
Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans)
** Continuation Coverage Rights Under COBRA**
Introduction
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has import ant
information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice
explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to
protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may
cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage
would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review
the Plan’s Summary Plan Description or contact the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an
individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower
costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for
another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept la te enrollees.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also
called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA co ntinuation
coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children coul d
become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries
who elect COBRA continuation must pay for COBRA continuation coverage.
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the followin g qualifying
events:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.
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COBRA
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because o f the
following qualifying events:
•
Your spouse dies;
• Your spouse’s hours of employment are reduced;
• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying
events:
•
The parent-employee dies;
• The parent- employee’s hours of employment are reduced;
• The parent- employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the Plan as a “dependent child.”
When is COBRA continuation coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a
qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:
• The end of employment or reduction of hours of employment;
•
Death of the employee;
• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
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COBRA
For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibi lity
for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.
You must provide this notice to the plan administrator.
How is COBRA continuation coverage provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each
of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.
Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation
coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months 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.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
Disability extension of 18-month period of COBRA continuation coverage
If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan
Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation
coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA
continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent
children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is
properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting
COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B,
or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This
extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the
Plan had the first qualifying event not occurred.
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Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the
Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP) , or other group health plan coverage
options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than
COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov .
Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?
In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial
enrollment period, you have an 8-month special enrollment period 1 to sign up for Medicare Part A or B, beginning on the earlier of
• The month after your employment ends; or
• The month after group health plan coverage based on current employment ends.
If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment p enalty
and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in
Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if
Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account
of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.
If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA
continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.
For more information visit https://www.medicare.gov/medicare-and-you.
If you have questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified
below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the
Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office
of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit
www.dol.gov/agencies/ebsa . (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s
website.) For more information about the Marketplace, visit www.healthcare.gov .
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COBRA
Keep your Plan informed of address changes
To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should
also keep a copy, for your records, of any notices you send to the Plan Administrator.
_____________
1 https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods
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LEGAL NOTICES
FAMILY MEDICAL LEAVE ACT (FMLA)
Family Medical Leave Act (FMLA)
Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period for
the following reasons:
• The birth of a child or placement of a child for adoption or foster care;
• To bond with a child (leave must be taken within one year of the child’s birth or placement);
• To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;
• For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s
job;
• For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse, child,
or parent.
An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks of F MLA
leave in a single 12-month period to care for the servicemember with a serious injury or illness.
Benefits & Protections
An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees may take
leave intermittently or on a reduced schedule.
Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee substitutes
accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.
While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave.
Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with equivalent pay,
benefits, and other employment terms and conditions.
An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA l eave,
opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.
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