Employee Benefits Guide
Effective September 1, 2023 – August 31, 2024
2023 - 2024 EMPLOYEE BENEFITS
About Your Benefits
At ISLEEP , we strive to offer a comprehensive and competitive benefits package to our employees. The goal of this guide is to walk you through your benefits and help you understand the options available to you.
Table of Contents
BENEFITS ELIGIBILITY ..................................................................................................................................................1 MEDICAL BENEFITS – Silver Plan ................................................................................................................................3 MEDICAL BENEFITS – Gold Plan..................................................................................................................................4 DENTAL BENEFITS .......................................................................................................................................................5 VISION BENEFITS ........................................................................................................................................................6 LIFE INSURANCE..........................................................................................................................................................7 VOLUNTARY BENEFITS................................................................................................................................................8 CONTACT INFORMATION & RESOURCES....................................................................................................................9 MEDICARE PART D NOTICE...................................................................................................................................... 10 WOMEN ’ S HEALTH & CANCER RIGHTS ACT............................................................................................................. 12 DESIGNATION OF PRIMARY CARE PROVIDER.......................................................................................................... 12 HEALTH INSURANCE MARKETPLACE COVERAGE .................................................................................................... 13 HIPAA NOTICE OF SPECIAL ENROLLMENT ............................................................................................................... 15 HIPAA NOTICE OF PRIVACY PRACTICES ................................................................................................................... 16 NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF 1996 ......................................................................... 16 THE CHILDREN ’ S HEALTH INSURANCE PROGRAM (CHIP) ........................................................................................ 17
BENEFITS ELIGIBILITY
Benefit Eligibility Waiting Period You are benefit eligible on the 1 st of the month following 30 days for full-time employment.
Who is Eligible? To be eligible for ISLEEP benefits, you must work at least 30 hours per week. You may choose to enroll your eligible dependents in the medical, dental, or vision insurance plans. Eligible dependents include:
Your spouse or qualified domestic partner
•
• Your eligible dependent children up to age 26, regardless of full-time student or marital status • Employees who experience a status change (such as part-time to full-time employment) may enroll in the plans on the first day of the month following the date of change as long as you have completed at least 30 days of employment . Domestic Partner Eligibility Criteria If you are enrolling a domestic partner, you will be asked to attest to your domestic partner relationship and that you have met all eligibility requirements listed below for the previous twelve months.
• Neither person was married or in a domestic partnership with someone else; • The persons are not related by blood; • Both are at least 18 years of age (with exceptions); • Both are capable of consenting to the domestic partnership; and • Both members may either be of the same sex or opposite sex under the age of 62, or • One or both is eligible for social security benefits and over the age of 62.
Making Changes You can make changes to your benefit choices once a year, during the ISLEEP Open Enrollment period in August. All changes are effective September 1, and all coverages you select will be effective for a full plan year. Because many of your benefits are available on a pre-tax basis, the IRS requires you to have a change in family status (a qualifying event) in order to make changes during the year. The IRS defines family status change as:
Marriage, legal separation or divorce
• •
Domestic partnership
• Birth, adoption or custody change of an eligible dependent • Beginning or ending of a spouse’s or domestic partner’s employment • An increase in the cost of health care coverage for you and your spouse or domestic partner because of your spouse’s or domestic partner’s employ ment • A change in employment (for either you or your spouse) from part-time to full-time or vice versa
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BENEFITS ELIGIBILITY (continued)
Employer Contribution As part of the employee compensation, ISLEEP provides contribution towards the benefit monthly premiums as follows:
75% of monthly premium for Employee only ( based on the Silver Plan )
Medical*
Dental
100% of monthly premium for Employee only
Vision
100% of monthly premium for Employee only
Basic Life/AD&D
Employee coverage only. This is an employer-paid benefit.
Employee may buy-up to the Anthem Blue Cross Gold PPO plan by paying the monthly cost difference via payroll deductions.
If You Waive Coverage If you choose to waive the medical and dental insurance when you are first eligible to enroll, you may only enroll if you have a qualifying family status event, or at the next open enrollment. If you are a late entrant to the dental plan, you will have waiting periods of certain benefits. If you would like to waive any of the coverages that ISLEEP offers, please see your Human Resources rep and complete the appropriate form declining the coverages .
If You Leave Your Job Your employer-sponsored benefits will end on the last day of the month for medical, dental, and vision coverages, while for the life benefits, they will end on the last day of employment. You and your dependents who are covered under your medical/dental/vision have the right to continue participation in group health coverage as allowed under the Consolidated Omnibus Budget Reconciliation Act (commonly referred to as “COBRA”). You have 60 days from your notification date or coverage-end date to enroll in COBRA. If you enroll in COBRA, you will pay monthly payments for the full premium plus a small percent of administration fee. COBRA coverage is generally available for up to 18 months, with additional extensions available under certain circumstances. For more information, you may contact your Human Resources representative.
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MEDICAL BENEFITS – Silver Plan
Base Plan Anthem Blue Cross and Blue Shield Silver PPO 3500/30%/9100
Network
Out-of-Network
Calendar Year Deductible
$3,500 single $7,000 family $9,100 single $18,200 family
$8,750 single $17,500 family $22,750 single $45,500 family
Annual Out-of-Pocket Maximum
Physician Services Office Visits
$40
50% after deductible
Specialist Visits
$90 $90
50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible
Urgent Care
Adult Preventive Services
Covered 100% - no copay Covered 100% - no copay
Well Child Care Exam
Outpatient Services Outpatient Surgery
30%
Diagnostic Lab / X-Ray MRI, CT Scan and PET Hospital Services Inpatient Hospitalization
30% after deductible 30% after deductible
30% after deductible
50% after deductible
Emergency Room (Copay waived if admitted)
$1,000 + 30% (deductible waived)
$1,000 + 30% (deductible waived)
Prescription Drugs Rx Deductible
No Rx deductible applies
-
Retail Pharmacy Generic Brand Formulary
$10 $40 $80
50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance
Brand Non-Formulary
Specialty
25%; max charge $500
Number of Day Supply
To 30-day supply
-
Mental or Nervous Disorders & Substance Abuse Inpatient
30% after deductible
50% after deductible 50% after deductible
Outpatient
$40
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MEDICAL BENEFITS – Gold Plan
Buy Up Plan Anthem Blue Cross and Blue Shield Gold PPO 2000/20%/5000
Network Services
Non-Network $5,000 single $10,000 family
Calendar Year Deductible
$2,000 single $4,000 family
Annual Out-of-Pocket Maximum
$5,000 single $10,000 / family
$12,500 single $25,000 family
Physician Services Office Visits
$20
50% after deductible
Specialist Visits
$50
50% after deductible
Urgent Care
$50
50% after deductible
Adult Preventive Services
Covered 100% - no copay
No coverage
Well Child Care Exam
Covered 100% - no copay
No coverage
Outpatient Services Outpatient Surgery (Surgery Center/Hospital)
20% after deductible
50% after deductible
Diagnostic Lab / X-Ray
20% after deductible
50% after deductible
MRI, CT Scan and PET (office)
20% after deductible
50% after deductible
Hospital Services Inpatient Hospitalization
20% after deductible
50% after deductible
Emergency Room (Copay waived if admitted)
$500 + 20% (deductible waived)
$500 + 20% (deductible waived)
Prescription Drugs Rx Deductible
-
Retail Pharmacy Generic Brand Formulary
$10 $40 $80
50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance
Brand Non-Formulary
Specialty
25%; max charge $500
Number of Day Supply
30 days
-
Mental or Nervous Disorders & Substance Abuse Inpatient
20% after deductible
50% after deductible
Outpatient
$20
50% after deductible
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DENTAL BENEFITS
Dental Plan
You have the option of dental care coverage through Principal, regardless of which medical plan you choose. With this plan you can see any dentist you wish for eligible dental care services. You are not required to choose a Principal network dentist, but when you do, you will have lower out-of-pocket costs. Benefit payments to non-dentists are based on Usual, Customary & Reasonable (UCR) fees as defined by Principal. Please consult the chart below for a summary of the Principal dental plan benefits. You have the option to waive this coverage.
DPPO Plan EPO
PPO Network
Non-Contracted/Out-of-Network
Maximum Contract Allowance
PPO Contracted Fee*
Program Allowance **
*PPO dentists agree to accept PPO Contracted Fees as payment in full. **Program allowance is the amount determined by a set of percentile (90 th ) level of charges for such services by providers with similar professional standing in the same geographical area.
Dental PPO
PPO Network
Non-Network
Annual Deductible (waived for preventive)
$50 individual $150 family
$50 individual $150 family
Calendar Year Annual Maximum Benefits
$1,500
$1,500
Preventive Services (cleanings, exams, x-rays)
100%
100% of UCR
Basic Services (extractions, fillings, periodontics) 80%
80% of UCR
Major Services
50%
50% of UCR
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VISION BENEFITS
Vision Plan
iSleep is offering you vision coverage with VSP through Principal. With this plan, you can see any vision provider you wish for vision care services. When you obtain services from providers who participate in the VSP Vision network, your coverage benefit is greater. When you obtain services from providers who do not participate in the network, your out-of-pocket expenses will be higher since VSP Vision pays a set dollar allowance for out-of-network claims.
Using VSP Vision is easy! With open access to see any eyecare provider, you can see the one who’s right for you.
Benefits
Frequency of Covered Services
Exam
Every 12 months Every 12 months Every 12 months Every 12 months
Lenses
Contacts (in lieu of glasses)
Frames Copay
$10 eye exam | $ 25 eyewear | $60 contacts
Network
Out-of-Network
Exams: Lenses: Single
Covered 100% after copay
$45 allowance
Covered 100% after copay Covered 100% after copay Covered 100% after copay
$30 allowance $50 allowance $65 allowance
Lined Bifocal Lined Trifocal
Contacts (in lieu of glasses) Medically Necessary
Covered 100% $200 allowance
$210 allowance $105 allowance
Elective
Frames
$200 allowance
$70 allowance
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LIFE INSURANCE
Basic Group Life/AD&D Insurance
iSleep provides all eligible employees working 30 hours per week with Basic Life and Accidental Death & Dismemberment (AD&D) insurance through Principal as follows:
Eligible Employee Group(s)
Life Benefit Amount
AD&D Benefit Amount
All Regular Employees
$25,000
$25,000
All guaranteed issue. Your beneficiary will receive the benefit amount in the event of your death. If your death is the result of an accident, your beneficiary will receive an additional amount equal to your Basic Life benefit amount. Coverage is reduced by 35% at age 65. See plan policy for more details. There is no cost to you for these benefits. The life coverage helps ensure that your loved ones will be provided with some financial security, in the event of your death. The Accidental Death & Dismemberment coverage provides additional protection in the event of an accidental death which also covers loss of limb or eye due to an accident. This is an employer paid benefit by iSleep.
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VOLUNTARY BENEFITS
Accident Insurance
Critical Illness Insurance
If you have an accident, will it hurt your bank account too? Accident insurance can give you something to fall back on. Every 10 minutes, over 700 Americans suffer an injury severe enough to seek medical help. About two-thirds of disabling injuries suffered by American workers are not work- related, and therefore not covered by workers’ compensation. This coverage provides a lump sum benefit based on the type of injury (or covered incident) you sustain or the type of treatment you need.
Could your bank account survive a serious illness? Get protected with group critical illness insurance from Principal The odds of developing cancer during a lifetime are one in two for men and one in three for women. Every 34 seconds someone in America will have a coronary event. Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose to purchase a minimum of $5,000 up to $50,000 of coverage – and you can use the money any way you see fit.
Sample Covered Conditions
Example of covered injuries include: • broken bones
▪
▪ Coronary artery bypass surgery ▪ End-stage renal (kidney) failure
Heart attack
• eye injuries
▪
Major organ failure Benign brain tumor
• burns
• ruptured discs
▪
▪ Parkinson’s disease
• torn ligaments
• concussion
▪
▪ Stroke Cancer conditions
Blindness
• coma due to a covered injury
• cuts repaired by
stitches
Cancer
Invasive cancer pays 100% of lump sum benefit
Some covered expenses include: • emergency room treatment
Please see policy definitions for complete details about these covered conditions.
• occupational therapy
• outpatient surgery facility
• speech therapy • chiropractic visit • physical therapy
Three reasons to buy this coverage at work 1. You get affordable rates when you buy this coverage through your employer, and the premiums are conveniently deducted from your paycheck. 2. Coverage is portable. You may take the coverage with you if you leave the company or retire without having to answer new health questions. Aflac will bill you directly. 3. Coverage becomes effective on the first day of the month in which payroll deductions begin.
• doctor office visit • hospitalization
How to apply Please see Ease for more details and enrollment information
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CONTACT INFORMATION & RESOURCES
Carriers
Group No.
Member Services
Website | Email Address
MEDICAL
Anthem Blue Cross
TBA
800-541-6652
www.anthem.com
DENTAL Principal
TBA
800-247-4695
www.principal.com
VISION
VSP (through Principal)
TBA
800-877-7195
www.vsp.com
LIFE/AD&D
Principal Life Insurance
TBA
800-245-1522
www.principal.com
VOLUNTARY BENEFITS
Principal
--
800-853-1371
GroupBenefitsAdmin@principal.com
BENEFITS SUPPORT Sara Boden, Account Executive Arrow Benefits
--
707-789-6992
SaraB@arrowbenefitsgroup.com
Alianza (Spanish) by Arrow Benefits
--
707-242-6703
ayuda@arrowbenefitsgroup.com
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MEDICARE PART D NOTICE
Important Notice from ISLEEP About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with ISLEEP 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. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription d rug coverage: 1. 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. 2. ISLEEP has determined that the prescription drug coverage offered by Anthem Blue Cross on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage . Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
__________________________________________________________________________
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 15 th - December 7 th .
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
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 be affected.
If you do decide to join a Medicare drug plan and drop your current ISLEEP coverage, be aware that you and your dependents will not be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with PINNACLE POWER SERVICES and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, 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 (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
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MEDICARE PART D NOTICE - Continued
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact ISLEEP Human Resources representative for further information. NOTE: You will 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 ISLEEP 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 han dbook 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 www.medicare.gov
•
• 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 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
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 www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
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WOMEN ’ S HEALTH & CANCER RIGHTS ACT
Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from a mastectomy, including lymphedemas? The Women’s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patients: • All stages of reconstruction of the breast on which the mastectomy was performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses • Treatment of physical complications of the mastectomy, including lymphedema
Contact your health provider for more information.
DESIGNATION OF PRIMARY CARE PROVIDER
All health providers generally require the designation of a primary care provider. You have the right to designate any primary care provider who participates in their network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact your health provider Member Services for assistance.
For children, you may designate a pediatrician as the primary care provider.
You do not need prior authorization from your health provider in order to obtain access to obstetrical or gynecological care from a health care professional in their 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 your health provider Member Services for assistance.
.
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HEALTH INSURANCE MARKETPLACE
COVERAGE
PART A: General Information
When key parts of the health care law took effect in 2014, there was a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in November for coverage effective January 1 st .
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.83% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your premium payments for coverage through the Marketplace are made on an after-tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or contact Human Resources.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.
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HEALTH INSURANCE MARKETPLACE
COVERAGE
PART B: Information About Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.
3. Employer name
4. Employer Identification Number (EIN)
________
ISLEEP
5. Employer address
6. Employer phone number
4690 Longley
_ _(833) 475-3372
______
7. City
8. State
9. ZIP code
Vallejo
NV
94592
_______
10. Who can we contact about employee health coverage at this job?
John Hickok
_______
11. Phone number (if different from above)
12. Email address
_____
jhickok@isleephst.com _______________________
Here is some basic information about health coverage offered by this employer:
• As your employer, we offer a health plan to:
All employees.
Some employees. Eligible employees are: Full-time employees working at least 30 hours a week
• With respect to dependents:
We do offer coverage. Eligible dependents are: spouse/domestic partner and children
We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly-employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
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HIPAA NOTICE OF SPECIAL ENROLLMENT
If you are declining enrollment for yourself or your dependents (including your spouse or domestic partner) 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 m ust request enrollment 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.
Also, you may be entitled to special enrollment rights pursuant to t he Children’s Health Insurance Program Reauthorization Act of 2009 (the Act) if you or your dependents:
1. Lose coverage under a Medicaid or State Plan (such as California’s Medi -Cal); or
2. Become eligible for group health premium assistance under a Medicaid plan or State Plan.
If a special enrollment right is provided pursuant to the Act, you may change your election consistent with such special enrollment right within 60 days .
Waiver of Coverage
If you elect to waive coverage for yourself or your dependents (including your spouse), you acknowledge that you and your spouse and/or dependent child(ren) can only enroll later during an annual open enrollment period. An exception to this is if you and your spouse and/or dependent child(ren) are entitled to enroll in accordance with the “Special Enrollment Rights” described above.
To request special enrollment or obtain more information, contact your Human Resources.
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HIPAA NOTICE OF PRIVACY PRACTICES
The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires that we maintain the privacy of protected health information, give notice of our legal duties and privacy practices regarding health information about you and follow the terms of our notice currently in effect.
If not attached to this document, you may request a copy of the current Privacy Practices, explaining how medical information about you may be used and disclosed and how you can get access to this information.
As Required by Law . We will disclose Health Information when required to do so by international, federal, state or local law.
You have the right to inspect and copy, right to an electronic copy of electronic medical records, right to get notice of a breach, right to amend, right to an accounting of disclosures, right to request restrictions, right to request confidential communications, right to a paper copy of this notice and the right to file a complaint if you believe your privacy rights have been violated.
NEWBORNS ’ AND MOTHERS ’ HEALTH PROTECTION ACT OF 1996
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 less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not pro hibit 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 issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
For more information, please visit the US Department of Labor and type Newborns' and Mothers' Health Protection Act in the Search Box.
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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 are 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, you can 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, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or http://www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the 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 permit you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 day s of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the Department of Labor electronically at http://www.askebsa.dol.gov or by calling toll- free 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, 2022. You should contact your State for further information on eligibility –
ALABAMA – Medicaid
CALIFORNIA – Medicaid
Website: http://myalhipp.com/ Phone: 1-855-692-5447
Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.gov
ALASKA – Medicaid
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
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
ARKANSAS – Medicaid
FLORIDA – Medicaid
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Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)
Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. com/hipp/index.html Phone: 1-877-357-3268
GEORGIA-Medicaid
MAINE-Medicaid
A HIPP Website: https://medicaid.georgia.gov/health-insurance- premium-payment-program-hipp Phone: 678-564-1162, Press 1GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party- liability/childrens- health-insurance-program-reauthorization- act-2009-chipra Phone: (678) 564-1162, Press 2
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 Phone: -800-977-6740. | TTY: Maine relay 711
INDIANA-Medicaid
MASSACHUSETTS-Medicaid and CHIP
Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/Phone: 1- 877-438-4479 All other Medicaid: https://www.in.gov/medicaid/ Phone 1-800-457-4584
Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840
IOWA-Medicaid and CHIP (Hawki)
MINNESOTA-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: 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
KANSAS-Medicaid
MISSOURI-Medicaid
Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884
Website:http://www.dss.mo.gov/mhd/participants/pag es/hipp.htm Phone: 573-751-2005
KENTUCKY – Medicaid
MONTANA – Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
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
LOUISIANA – Medicaid
NEBRASKA-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: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178
SOUTH CAROLINA-Medicaid
NEVADA-Medicaid
Website: https://www.scdhhs.gov Phone: 1-888-549-0820
Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
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NEW HAMPSHIRE-Medicaid
SOUTH DAKOTA-Medicaid
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
Website: http://dss.sd.gov Phone: 1-888-828-0059
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NEW JERSEY-Medicaid and CHIP
TEXAS-Medicaid
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
Website: http://gethipptexas.com/ Phone: 1-800-440-0493
NEW YORK-Medicaid
UTAH – Medicaid and CHIP
Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669
NORTH CAROLINA – Medicaid
VERMONT – Medicaid
Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
NORTH DAKOTA – Medicaid
VIRGINIA – Medicaid and CHIP
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825
Website: https://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282
OKLAHOMA-Medicaid and CHIP
WASHINGTON – Medicaid
Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022
Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
OREGON-Medicaid
WEST VIRGINIA – Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075
Website: https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone: 304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
PENNSYLVANIA-Medicaid
WISCONSIN – Medicaid and CHIP
Website:https://www.dhs.pa.gov/Services/Assistance/Pages/HIP P-Program.aspx Phone: 1-800-692-7462
https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002
RHODE ISLAND-Medicaid and CHIP
WYOMING – Medicaid
Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
https://health.wyo.gov/healthcarefin/medicaid/programs -and-eligibility/ Phone: 1-800-251-1269
To see if any more States have added a premium assistance program since January 31, 2022, 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 www.dol.gov/agencies/ebsa http://www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 12/31/2023)
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