Page 25 - Dent Wizard 2022 Benefits Guide Spanish
P. 25
Coordinating Other Coverage With Medicare Part D
Generally speaking, if you decide to join a Medicare drug plan while covered under the Dealer Tire, LLC Plan due to your empl oyment (or someone else’s
employment, such as a spouse or parent), your coverage under the Dealer Tire, LLC Plan will not be affected. For most persons covered under the Plan, the P lan will
pay prescription drug benefits first, and Medicare will determine its payments second. For more information about this iss ue of what program pays first and what
program pays second, see the Plan’s summary plan description or contact Medicare at the telephone number or web address liste d below. If you do decide to join a
Medicare drug plan and drop your Dealer Tire, LLC prescr iption drug coverage, be aware that you and your dependents may not be able to get this coverage back. To
regain coverage you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description
to determine if and when you are allowed to add coverage. For More Information About This Notice or Your Current Prescription Drug Coverage…
Contact the person listed below for further information, or call 2164327401. NOTE: You’ll get thi s notice each year.
You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Dealer Tire, LLC changes. You also may request a copy.
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 handbook 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 whether or not you are required to pay a higher premium (a penalty).
Date: September 25, 2020
Name of Entity/Sender: Kellye Khas
Contact—Position/Office: Senior Manager, Total Rewards
Address: 7012 Euclid Avenue
Cleveland, OH 44103
Phone Number: 2164327401
Nothing in this notice gives you or your dependents a right to coverage under the Plan. Your (or your dependents’) right to coverage under the Plan is determined
solely under the terms of the Plan.
WOMEN’S HEALTH AND CANCER RIGHTS NOTICE
Dealer Tire, LLC Employee Health Care Plan is required by law to provide you with the following notice: The Women’s Health an d Cancer Rights Act of 1998
(“WHCRA”) provides certain protections for individuals receiving mastectomy- related benefits. Coverage will be provided in a manner determined in consultation
with the attending physician and the patient for: • All stages of reconstruction of the breast on which the mas tectomy was performed; • Surgery and reconstruction
of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the maste ctomy, including lymphedemas. The
Dealer Tire, LLC Employee Health Care Plan pr ovide(s) medical coverage for mastectomies and the related procedures listed above, subject to the same deductibles
and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more informatio n on WHCRA benefits, please refer to
your or contact your Plan Administrator at: Kellye Khas Senior Manager, Total Rewards 2164327401
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 or your dependents in this plan if you or your dependents lose eligi bility for that other coverage (or if the employer stops contributing towards
your or your dependents’ other coverage). However, you must 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 result of marriage, birth, adoption, or placement for adoption, you may be able t o enroll yourself and your dependents.
However, you must request enrollment within 30 days af ter the marriage, birth, adoption, or placement for adoption.
Special enrollment rights also may exist in the following circumstances:
• If you or your dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Progra m (CHIP) coverage and you request
enrollment within 60 days after that coverage ends; or
• If you or your dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with resp ect to coverage under this
plan and you request enrollment within 60 days after the determination of eligibility for such assistance.
Note: The 60 -day period for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state CHIP. As described above, a 60 -
day period applies to most special enrollments.
To request special enrollment or obtain more information, contact the Plan Administrator.
REQUIRED WARNING: GINA Warning for Wellness Program Materials Requesting Medical Information
In answering questions contained in the Health Risk Assessment (HRA) as part of Dealer Tire’s wellness program, do not inclu de any genetic information. The Genetic
Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities cov ered by GINA 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 as king that you not provide any genetic
information when responding to this request. “Genetic information” as defined by GINA, includes an individual’s family medical history, 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 receiv ing assistive reproductive services.
Please do not include any family medical history or any information related to genetic testing, genetic services, genetic counseling or genetic diseases for which an
individual may be at risk.
Generally speaking, if you decide to join a Medicare drug plan while covered under the Dealer Tire, LLC Plan due to your empl oyment (or someone else’s
employment, such as a spouse or parent), your coverage under the Dealer Tire, LLC Plan will not be affected. For most persons covered under the Plan, the P lan will
pay prescription drug benefits first, and Medicare will determine its payments second. For more information about this iss ue of what program pays first and what
program pays second, see the Plan’s summary plan description or contact Medicare at the telephone number or web address liste d below. If you do decide to join a
Medicare drug plan and drop your Dealer Tire, LLC prescr iption drug coverage, be aware that you and your dependents may not be able to get this coverage back. To
regain coverage you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description
to determine if and when you are allowed to add coverage. For More Information About This Notice or Your Current Prescription Drug Coverage…
Contact the person listed below for further information, or call 2164327401. NOTE: You’ll get thi s notice each year.
You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Dealer Tire, LLC changes. You also may request a copy.
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 handbook 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 whether or not you are required to pay a higher premium (a penalty).
Date: September 25, 2020
Name of Entity/Sender: Kellye Khas
Contact—Position/Office: Senior Manager, Total Rewards
Address: 7012 Euclid Avenue
Cleveland, OH 44103
Phone Number: 2164327401
Nothing in this notice gives you or your dependents a right to coverage under the Plan. Your (or your dependents’) right to coverage under the Plan is determined
solely under the terms of the Plan.
WOMEN’S HEALTH AND CANCER RIGHTS NOTICE
Dealer Tire, LLC Employee Health Care Plan is required by law to provide you with the following notice: The Women’s Health an d Cancer Rights Act of 1998
(“WHCRA”) provides certain protections for individuals receiving mastectomy- related benefits. Coverage will be provided in a manner determined in consultation
with the attending physician and the patient for: • All stages of reconstruction of the breast on which the mas tectomy was performed; • Surgery and reconstruction
of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the maste ctomy, including lymphedemas. The
Dealer Tire, LLC Employee Health Care Plan pr ovide(s) medical coverage for mastectomies and the related procedures listed above, subject to the same deductibles
and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more informatio n on WHCRA benefits, please refer to
your or contact your Plan Administrator at: Kellye Khas Senior Manager, Total Rewards 2164327401
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 or your dependents in this plan if you or your dependents lose eligi bility for that other coverage (or if the employer stops contributing towards
your or your dependents’ other coverage). However, you must 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 result of marriage, birth, adoption, or placement for adoption, you may be able t o enroll yourself and your dependents.
However, you must request enrollment within 30 days af ter the marriage, birth, adoption, or placement for adoption.
Special enrollment rights also may exist in the following circumstances:
• If you or your dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Progra m (CHIP) coverage and you request
enrollment within 60 days after that coverage ends; or
• If you or your dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with resp ect to coverage under this
plan and you request enrollment within 60 days after the determination of eligibility for such assistance.
Note: The 60 -day period for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state CHIP. As described above, a 60 -
day period applies to most special enrollments.
To request special enrollment or obtain more information, contact the Plan Administrator.
REQUIRED WARNING: GINA Warning for Wellness Program Materials Requesting Medical Information
In answering questions contained in the Health Risk Assessment (HRA) as part of Dealer Tire’s wellness program, do not inclu de any genetic information. The Genetic
Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities cov ered by GINA 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 as king that you not provide any genetic
information when responding to this request. “Genetic information” as defined by GINA, includes an individual’s family medical history, 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 receiv ing assistive reproductive services.
Please do not include any family medical history or any information related to genetic testing, genetic services, genetic counseling or genetic diseases for which an
individual may be at risk.
