Page 20 - Goodwill 2021 Annual Benefits Enrollment
P. 20
Goodwill Industries
Keep Your Plan Informed of Address As stated earlier in this notice, a special enrollment opportunity
Changes may be available in the future if you or your dependents lose
To protect your family’s rights, let the Plan Administrator know other coverage. This special enrollment opportunity will not
be available when other coverage ends, however, unless you
about any changes in the addresses of family members. You provide a written statement now explaining the reason that
should also keep a copy, for your records, of any notices you you are declining coverage for yourself or your dependent(s).
send to the Plan Administrator.
Failing to accurately complete and return this form for each
HIPAA Privacy Notice: Protecting person for whom you are declining coverage may eliminate this
special enrollment opportunity for the person(s) for whom a
Your Health Information Privacy statement is not completed, even if other coverage is currently
Rights in efect and is later lost. In addition, unless you indicate in
The Plan’s policies protecting your privacy rights and your rights the statement that you are declining coverage because other
coverage is in efect, you may not have this special enrollment
under the law are described in the Plan’s Notice of Privacy opportunity for the person(s) covered by the statement. (See
Practices. Please contact your medical plan carrier to request a the paragraphs above, however, regarding enrollment in the
copy of the Notice. event of marriage, birth, adoption, placement for adoption, loss
of eligibility for Medicaid or a state CHIP, and gaining eligibility
Goodwill’s Initial Notice of Your for a state premium assistance subsidy through Medicaid or
HIPAA Special Enrollment Rights a state CHIP.) To request special enrollment or obtain more
If you are declining enrollment for yourself or your dependents information, contact your plan administrator.
(including your spouse) because of other health insurance or
group health plan coverage, you may be able to enroll yourself Health Insurance Marketplace
or your dependents in this plan if you or your dependents Coverage Options and Your Health
lose eligibility for that other coverage (or if the employer Coverage
stops contributing towards your or your dependents’ other
coverage). You will be required to submit a signed statement PART A: General Information
that this other coverage was the reason for waiving enrollment When key parts of the health care law took efect in 2014, there
originally. To be eligible for this special enrollment opportunity was a new way to buy health insurance: the Health Insurance
you must request enrollment within 31 days after your or your Marketplace. To assist you as you evaluate options for you
dependents’ other coverage ends (or after the employer stops and your family, this notice provides some basic information
contributing toward the other coverage). In addition, if you about the Marketplace and employment-based health coverage
have a new dependent as result of marriage, birth, adoption, ofered by your employer.
or placement for adoption, you may be able to enroll yourself
and your dependents. However, you must request enrollment What is the Health Insurance Marketplace?
within 31 days after the marriage, birth, adoption, or placement
for adoption. Special enrollment rights also may exist in the The Marketplace is designed to help you ind health insurance
following circumstances: that meets your needs and its your budget. The Marketplace
ofers “one-stop shopping” to ind and compare private health
If you or your dependents experience a loss of eligibility for insurance options. You may also be eligible for a tax credit that
Medicaid or a state Children’s Health Insurance Program lowers your monthly premium right away. Open enrollment
(CHIP) coverage and you request enrollment within 60 for health insurance coverage through the Marketplace begins
days after that coverage ends; or in November each year for coverage starting as early as the
If you or your dependents become eligible for a state immediately following January 1.
premium assistance subsidy through Medicaid or a state
CHIP with respect to coverage under this plan and you
request enrollment within 60 days after the determination
of eligibility for such assistance.
20
Keep Your Plan Informed of Address As stated earlier in this notice, a special enrollment opportunity
Changes may be available in the future if you or your dependents lose
To protect your family’s rights, let the Plan Administrator know other coverage. This special enrollment opportunity will not
be available when other coverage ends, however, unless you
about any changes in the addresses of family members. You provide a written statement now explaining the reason that
should also keep a copy, for your records, of any notices you you are declining coverage for yourself or your dependent(s).
send to the Plan Administrator.
Failing to accurately complete and return this form for each
HIPAA Privacy Notice: Protecting person for whom you are declining coverage may eliminate this
special enrollment opportunity for the person(s) for whom a
Your Health Information Privacy statement is not completed, even if other coverage is currently
Rights in efect and is later lost. In addition, unless you indicate in
The Plan’s policies protecting your privacy rights and your rights the statement that you are declining coverage because other
coverage is in efect, you may not have this special enrollment
under the law are described in the Plan’s Notice of Privacy opportunity for the person(s) covered by the statement. (See
Practices. Please contact your medical plan carrier to request a the paragraphs above, however, regarding enrollment in the
copy of the Notice. event of marriage, birth, adoption, placement for adoption, loss
of eligibility for Medicaid or a state CHIP, and gaining eligibility
Goodwill’s Initial Notice of Your for a state premium assistance subsidy through Medicaid or
HIPAA Special Enrollment Rights a state CHIP.) To request special enrollment or obtain more
If you are declining enrollment for yourself or your dependents information, contact your plan administrator.
(including your spouse) because of other health insurance or
group health plan coverage, you may be able to enroll yourself Health Insurance Marketplace
or your dependents in this plan if you or your dependents Coverage Options and Your Health
lose eligibility for that other coverage (or if the employer Coverage
stops contributing towards your or your dependents’ other
coverage). You will be required to submit a signed statement PART A: General Information
that this other coverage was the reason for waiving enrollment When key parts of the health care law took efect in 2014, there
originally. To be eligible for this special enrollment opportunity was a new way to buy health insurance: the Health Insurance
you must request enrollment within 31 days after your or your Marketplace. To assist you as you evaluate options for you
dependents’ other coverage ends (or after the employer stops and your family, this notice provides some basic information
contributing toward the other coverage). In addition, if you about the Marketplace and employment-based health coverage
have a new dependent as result of marriage, birth, adoption, ofered by your employer.
or placement for adoption, you may be able to enroll yourself
and your dependents. However, you must request enrollment What is the Health Insurance Marketplace?
within 31 days after the marriage, birth, adoption, or placement
for adoption. Special enrollment rights also may exist in the The Marketplace is designed to help you ind health insurance
following circumstances: that meets your needs and its your budget. The Marketplace
ofers “one-stop shopping” to ind and compare private health
If you or your dependents experience a loss of eligibility for insurance options. You may also be eligible for a tax credit that
Medicaid or a state Children’s Health Insurance Program lowers your monthly premium right away. Open enrollment
(CHIP) coverage and you request enrollment within 60 for health insurance coverage through the Marketplace begins
days after that coverage ends; or in November each year for coverage starting as early as the
If you or your dependents become eligible for a state immediately following January 1.
premium assistance subsidy through Medicaid or a state
CHIP with respect to coverage under this plan and you
request enrollment within 60 days after the determination
of eligibility for such assistance.
20
