Page 17 - Goodwill 2021 Annual Benefits Enrollment
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2021 Legal Notices
For More Information About Your Options Report Eligibility Changes in a Timely
Under Medicare Prescription Drug Manner
Coverage It is your responsibility to notify the Beneits Department
More detailed information about Medicare plans that ofer when a dependent becomes eligible or ceases to be eligible
prescription drug coverage is in the “Medicare & You” for coverage under our beneit plans. All eligibility changes
handbook. You’ll get a copy of the handbook in the mail every should be reported within 31 days of the event. Failure to
year from Medicare. You may also be contacted directly by report changes in a timely manner can impact your ability to
Medicare drug plans. For more information about Medicare add newly eligible dependents or discontinue pre-tax premium
prescription drug coverage: Visit www.medicare.gov; contributions on ineligible dependents. In addition, failure to
Call your State Health Insurance Assistance Program (see report a loss of eligibility due to legal separation or divorce or
the inside back cover of your copy of the “Medicare & You” a dependent that has otherwise ceased to be eligible, such as
handbook for their telephone number) for personalized help; a child reaching the maximum dependent child age limit, can
Call 800-MEDICARE 800.633.4227).TTY users should call impact your dependent’s rights for group health plan coverage
877.486.2048. If you have limited income and resources, under the federal law known as COBRA. If you fail to report the
extra help paying for Medicare prescription drug coverage is loss of eligibility within 60 days of the event, your dependents
available. For information about this extra help, visit Social may be left with no continuation coverage under our plan.
Security on the web at www.socialsecurity.gov, or call them Please see your COBRA notice or your group health plan
at 800.772.1213 (TTY 800.325.0778). summary plan description for additional information.
Remember: Notice Regarding the Women’s
Keep this creditable coverage notice. If you decide to join one
of the Medicare drug plans, you may be required to provide a Health and Cancer Rights Act
copy of this notice when you join to show whether or not you If you have had or are going to have a mastectomy, you may
have maintained creditable coverage and, therefore, whether or be entitled to certain beneits under the Women’s Health and
not you are required to pay a higher premium (a penalty). Cancer Rights Act of 1998 (WHCRA). For individuals receiving
mastectomy-related beneits, coverage will be provided in a
Date: November 1, 2020 manner determined in consultation with the attending physician
Name of Entity/Sender: Goodwill Industries of Middle and the patient, for:
Tennessee, Inc.
Contact—Position/Oice: Human Resources All stages of reconstruction of the breast on which the
Address: 937 Herman Street, Nashville mastectomy was performed;
TN 37208 Surgery and reconstruction of the other breast to produce
Phone Number: 615.346.1283 a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy,
including lymphedema.
These beneits will be provided subject to the same
deductibles and coinsurance applicable to other medical and
surgical beneits provided under this plan. If you would like
more information on WHCRA beneits, contact your plan
administrator.
17
For More Information About Your Options Report Eligibility Changes in a Timely
Under Medicare Prescription Drug Manner
Coverage It is your responsibility to notify the Beneits Department
More detailed information about Medicare plans that ofer when a dependent becomes eligible or ceases to be eligible
prescription drug coverage is in the “Medicare & You” for coverage under our beneit plans. All eligibility changes
handbook. You’ll get a copy of the handbook in the mail every should be reported within 31 days of the event. Failure to
year from Medicare. You may also be contacted directly by report changes in a timely manner can impact your ability to
Medicare drug plans. For more information about Medicare add newly eligible dependents or discontinue pre-tax premium
prescription drug coverage: Visit www.medicare.gov; contributions on ineligible dependents. In addition, failure to
Call your State Health Insurance Assistance Program (see report a loss of eligibility due to legal separation or divorce or
the inside back cover of your copy of the “Medicare & You” a dependent that has otherwise ceased to be eligible, such as
handbook for their telephone number) for personalized help; a child reaching the maximum dependent child age limit, can
Call 800-MEDICARE 800.633.4227).TTY users should call impact your dependent’s rights for group health plan coverage
877.486.2048. If you have limited income and resources, under the federal law known as COBRA. If you fail to report the
extra help paying for Medicare prescription drug coverage is loss of eligibility within 60 days of the event, your dependents
available. For information about this extra help, visit Social may be left with no continuation coverage under our plan.
Security on the web at www.socialsecurity.gov, or call them Please see your COBRA notice or your group health plan
at 800.772.1213 (TTY 800.325.0778). summary plan description for additional information.
Remember: Notice Regarding the Women’s
Keep this creditable coverage notice. If you decide to join one
of the Medicare drug plans, you may be required to provide a Health and Cancer Rights Act
copy of this notice when you join to show whether or not you If you have had or are going to have a mastectomy, you may
have maintained creditable coverage and, therefore, whether or be entitled to certain beneits under the Women’s Health and
not you are required to pay a higher premium (a penalty). Cancer Rights Act of 1998 (WHCRA). For individuals receiving
mastectomy-related beneits, coverage will be provided in a
Date: November 1, 2020 manner determined in consultation with the attending physician
Name of Entity/Sender: Goodwill Industries of Middle and the patient, for:
Tennessee, Inc.
Contact—Position/Oice: Human Resources All stages of reconstruction of the breast on which the
Address: 937 Herman Street, Nashville mastectomy was performed;
TN 37208 Surgery and reconstruction of the other breast to produce
Phone Number: 615.346.1283 a symmetrical appearance;
Prostheses; and
Treatment of physical complications of the mastectomy,
including lymphedema.
These beneits will be provided subject to the same
deductibles and coinsurance applicable to other medical and
surgical beneits provided under this plan. If you would like
more information on WHCRA beneits, contact your plan
administrator.
17
