Page 19 - Watermark Retirement Communities 2022 Benefits Guide Logan Square Union Before

Required Notices

Notice of Patient Protection Disclosure
United Healthcare generally allows the designation of a primary care provider. You have the right to designate any primary care
provider who participates in our 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, contact Human Resources.

Women’s Health and Cancer Rights Act 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 benefits, 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 provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits
provided under this plan. Therefore, the following deductibles and coinsurance apply.
If you would like more information on WHCRA benefits, contact your plan administrator.

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 you 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.
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 within 60 days after the determination of eligibility for such
assistance.
Note: The 60-day period for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state
CHIP. As described above, a 30-day period applies to most special enrollments. To request special enrollment or obtain more
information, contact Brenda Huffman, Benefits Manager, (520) 797-4000 ext. 3023.

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may
have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your
children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs, but you may be able to buy
individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or
CHIP office to find out if premium assistance is available.

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