Page 28 - 2022 Benegit Guide

Required Notices

Selection of a Primary Care Provider
This plan generally allows the designation of a primary care provider. You have the right to designate any
primary care provider who participates in the network and who is available to accept you or your family
members. For information on how to select a primary care provider, and for a list of the participating primary
care providers, visit anthem.com or contact customer service at the phone number listed on the back of your
ID card. For children, you may designate a pediatrician as the primary care provider.

Women’s Health and Cancer Rights Act (WHCRA) Notice
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related bene-
fits, 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 mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses; and treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be subject to the same deductibles and coinsurance applicable to other medical and
surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your
plan administrator 1-833-999-0331.

Direct Access to Obstetricians and Gynecologists
You do not need prior authorization from the plan or from any other person (including a primary care provider)
in order to obtain access to obstetrical or gynecological care from a health care professional in our network
who specializes in obstetrics or gynecology. The health care professional, however, may be required to
comply with certain procedures, including obtaining prior authorization for certain services, following a
pre-approved treatment plan, or procedures for making referrals. For a list of participating health care
professionals who specialize in obstetrics or gynecology, visit anthem.com or contact customer service at the
phone number listed on the back of your ID card.

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 eligibility 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 to enroll yourself and your dependents. However, you must request enrollment within 30 days
after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more
information, contact the Benefits Team at HR.Benefits@americansignature.com or call 1-855-819-0118.

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
Program (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 respect to coverage under this plan and you request enrollment 60 after the determination
of eligibility for such assistance.

28 2022 Health and Benefits Guide