Page 19 - 2020 Goodwill Benefits Guide
P. 19
2020
Legal Notices
HIPAA Privacy Notice: Protecting Your Health As stated earlier in this notice, a
Information Privacy Rights special enrollment opportunity may be
available in the future if you or your
The Plan’s policies protecting your privacy rights and your rights under the law are dependents lose other coverage. This
described in the Plan’s Notice of Privacy Practices. Please contact your medical plan special enrollment opportunity will not
carrier to request a copy of the Notice. be available when other coverage ends,
however, unless you provide a written
Goodwill’s Initial Notice Of Your HIPAA Special statement now explaining the reason
Enrollment Rights that you are declining coverage for
yourself or your dependent(s). Failing
If you are declining enrollment for yourself or your dependents (including your to accurately complete and return this
spouse) because of other health insurance or group health plan coverage, you may form for each person for whom you
be able to enroll yourself or your dependents in this plan if you or your dependents are declining coverage may eliminate
lose eligibility for that other coverage (or if the employer stops contributing towards this special enrollment opportunity for
your or your dependents’ other coverage). You will be required to submit a signed the person(s) for whom a statement is
statement that this other coverage was the reason for waiving enrollment originally. To not completed, even if other coverage
be eligible for this special enrollment opportunity you must request enrollment within is currently in efect and is later lost.
31 days after your or your dependents’ other coverage ends (or after the employer In addition, unless you indicate in
stops contributing toward the other coverage). In addition, if you have a new the statement that you are declining
dependent as result of marriage, birth, adoption, or placement for adoption, you may coverage because other coverage
be able to enroll yourself and your dependents. However, you must request enrollment is in efect, you may not have this
within 31 days after the marriage, birth, adoption, or placement for adoption. Special special enrollment opportunity for the
enrollment rights also may exist in the following circumstances: person(s) covered by the statement.
If you or your dependents experience a loss of eligibility for Medicaid or a state (See the paragraphs above, however,
Children’s Health Insurance Program (CHIP) coverage and you request enrollment regarding enrollment in the event of
within 60 days after that coverage ends; or marriage, birth, adoption, placement for
If you or your dependents become eligible for a state premium assistance subsidy adoption, loss of eligibility for Medicaid
through Medicaid or a state CHIP with respect to coverage under this plan and or a state CHIP, and gaining eligibility
you request enrollment within 60 days after the determination of eligibility for for a state premium assistance subsidy
such assistance. through Medicaid or a state CHIP.) To
request special enrollment or obtain
more information, contact your plan
administrator.
19
Legal Notices
HIPAA Privacy Notice: Protecting Your Health As stated earlier in this notice, a
Information Privacy Rights special enrollment opportunity may be
available in the future if you or your
The Plan’s policies protecting your privacy rights and your rights under the law are dependents lose other coverage. This
described in the Plan’s Notice of Privacy Practices. Please contact your medical plan special enrollment opportunity will not
carrier to request a copy of the Notice. be available when other coverage ends,
however, unless you provide a written
Goodwill’s Initial Notice Of Your HIPAA Special statement now explaining the reason
Enrollment Rights that you are declining coverage for
yourself or your dependent(s). Failing
If you are declining enrollment for yourself or your dependents (including your to accurately complete and return this
spouse) because of other health insurance or group health plan coverage, you may form for each person for whom you
be able to enroll yourself or your dependents in this plan if you or your dependents are declining coverage may eliminate
lose eligibility for that other coverage (or if the employer stops contributing towards this special enrollment opportunity for
your or your dependents’ other coverage). You will be required to submit a signed the person(s) for whom a statement is
statement that this other coverage was the reason for waiving enrollment originally. To not completed, even if other coverage
be eligible for this special enrollment opportunity you must request enrollment within is currently in efect and is later lost.
31 days after your or your dependents’ other coverage ends (or after the employer In addition, unless you indicate in
stops contributing toward the other coverage). In addition, if you have a new the statement that you are declining
dependent as result of marriage, birth, adoption, or placement for adoption, you may coverage because other coverage
be able to enroll yourself and your dependents. However, you must request enrollment is in efect, you may not have this
within 31 days after the marriage, birth, adoption, or placement for adoption. Special special enrollment opportunity for the
enrollment rights also may exist in the following circumstances: person(s) covered by the statement.
If you or your dependents experience a loss of eligibility for Medicaid or a state (See the paragraphs above, however,
Children’s Health Insurance Program (CHIP) coverage and you request enrollment regarding enrollment in the event of
within 60 days after that coverage ends; or marriage, birth, adoption, placement for
If you or your dependents become eligible for a state premium assistance subsidy adoption, loss of eligibility for Medicaid
through Medicaid or a state CHIP with respect to coverage under this plan and or a state CHIP, and gaining eligibility
you request enrollment within 60 days after the determination of eligibility for for a state premium assistance subsidy
such assistance. through Medicaid or a state CHIP.) To
request special enrollment or obtain
more information, contact your plan
administrator.
19
