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For more information Remember: Keep this Creditable Coverage notice. If you decide to join one of the
about your options under Medicare drug plans, you may be required to provide a copy of this notice when you
Medicare prescription drug join to show whether or not you have maintained creditable coverage and whether or
coverage… not you are required to pay a higher premium (a penalty).
Date: October 2014
More detailed information about Name of Entity/Sender: [Client Name]
Medicare plans that offer prescription Contact—Position/Ofice: [Name],
drug coverage is in the “Medicare & [Title]
You” handbook. You’ll get a copy of the Address: [Address]
handbook in the mail every year from [City]
Medicare. You may also be contacted Phone Number: [State]
directly by Medicare drug plans.
Nothing in this notice gives you or your dependents a right to coverage under the
For more information about Medicare Plan. Your (or your dependents’) right to coverage under the Plan is determined solely
prescription drug coverage: under the terms of the Plan.
Visit www.medicare.gov
Call your State Health Insurance HIPAA Special Enrollment Notice
Assistance Program (see the inside
back cover of your copy of the Declining Coverage
“Medicare & You” handbook for their
telephone number) for personalized If you are declining coverage under [Client]’s health plan for yourself or your
help, dependents (including your spouse) because of other health coverage, in the future
Call 1-800-MEDICARE you may be able to enroll yourself or your dependents in this plan provided that you
(1-800-633-4227). TTY users should request enrollment within 30 days after your other coverage ends. In addition, if you
call 1-877-486-2048. acquire other coverage or a new dependent as a result of marriage, birth, adoption
or placement for adoption, you may be able to enroll yourself and your dependents,
If you have limited income and
resources, extra help paying for provided that you request enrollment within 30 days after you acquire new coverage,
Medicare prescription drug coverage marriage, birth, adoption, or placement of adoption.
is available. For information about
this extra help, visit Social Security on Eligible for Coverage
the Web at www.socialsecurity.gov, For team members hired in full-time positions, beneits will be available 1st of the
or call them at 1-800-772-1213 (TTY month following 60 days of employment. Team members hired in part-time positions
1-800-325-0778). will be offered coverage after 1 full year of service if hours worked averaged more
than 30 hours per week.
For team members who experience a life event (marriage, divorce, birth or adoption of
baby, loss of job, or get a job with beneits.) You have 30 days from the life event or
status change to request a change or cancel coverage.
Once enrolled beneits will remain in effect until the next annual enrollment unless you
experience a life event.
[Client]
For more information Remember: Keep this Creditable Coverage notice. If you decide to join one of the
about your options under Medicare drug plans, you may be required to provide a copy of this notice when you
Medicare prescription drug join to show whether or not you have maintained creditable coverage and whether or
coverage… not you are required to pay a higher premium (a penalty).
Date: October 2014
More detailed information about Name of Entity/Sender: [Client Name]
Medicare plans that offer prescription Contact—Position/Ofice: [Name],
drug coverage is in the “Medicare & [Title]
You” handbook. You’ll get a copy of the Address: [Address]
handbook in the mail every year from [City]
Medicare. You may also be contacted Phone Number: [State]
directly by Medicare drug plans.
Nothing in this notice gives you or your dependents a right to coverage under the
For more information about Medicare Plan. Your (or your dependents’) right to coverage under the Plan is determined solely
prescription drug coverage: under the terms of the Plan.
Visit www.medicare.gov
Call your State Health Insurance HIPAA Special Enrollment Notice
Assistance Program (see the inside
back cover of your copy of the Declining Coverage
“Medicare & You” handbook for their
telephone number) for personalized If you are declining coverage under [Client]’s health plan for yourself or your
help, dependents (including your spouse) because of other health coverage, in the future
Call 1-800-MEDICARE you may be able to enroll yourself or your dependents in this plan provided that you
(1-800-633-4227). TTY users should request enrollment within 30 days after your other coverage ends. In addition, if you
call 1-877-486-2048. acquire other coverage or a new dependent as a result of marriage, birth, adoption
or placement for adoption, you may be able to enroll yourself and your dependents,
If you have limited income and
resources, extra help paying for provided that you request enrollment within 30 days after you acquire new coverage,
Medicare prescription drug coverage marriage, birth, adoption, or placement of adoption.
is available. For information about
this extra help, visit Social Security on Eligible for Coverage
the Web at www.socialsecurity.gov, For team members hired in full-time positions, beneits will be available 1st of the
or call them at 1-800-772-1213 (TTY month following 60 days of employment. Team members hired in part-time positions
1-800-325-0778). will be offered coverage after 1 full year of service if hours worked averaged more
than 30 hours per week.
For team members who experience a life event (marriage, divorce, birth or adoption of
baby, loss of job, or get a job with beneits.) You have 30 days from the life event or
status change to request a change or cancel coverage.
Once enrolled beneits will remain in effect until the next annual enrollment unless you
experience a life event.
[Client]
