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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