Page 22 - 2022 Benefit Guide DyAG

Medicare Part D Creditable Coverage Notice

If you have Medicare or will become eligible for Medicare in the next 12 months, the notice contains important
information with regards to Medicare eligible member’s not enrolling in Medicare Part D due to being covered for
prescription drugs through a Fives Health Plan. If you did not receive this notice and would like a copy notify the Plan
Administrator.

Women’s Health and Cancer Rights Act

Do you know that your plan, as required by the Women’s Health and Cancer Right Act of 1998, provides benefits for
mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the
breasts, prostheses and treatment for complications resulting from a mastectomy, including lymphedema? Call your
Plan Administrator for more information.

Medicaid and the Children’s Health Insurance Program (CHIP)
Offer Free Or Low-Cost Health Coverage To Children And Families

If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have
premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP
programs to help people who are eligible for employer-sponsored health coverage but need assistance in paying their
health premiums.

If you or your dependents are already enrolled in Medicaid or CHIP, you can contact your State Medicaid or CHIP office
to find out if premium assistance is available. A list of all States and contact information can be found at
www.dol.gov/ebsa/chipmodelnotice.doc.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents
might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS
NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that
might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your
employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your
dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity,
and you must request coverage within 60 days of being determined eligible for premium assistance.

For more information on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
OMB Control Number 1210-0137 (expires 09/30/2013)

Summary Annual Report for Fives Health and Welfare Plan

The annual report for the Fives Health and Welfare Plan (EIN 38-3503183, Plan Number 501) for the 1/1/2020 – 12/31/2020
year has been filed with the Employee Benefits Security Administration, as required under the Employee Retirement Income
Security Act of 1974 (ERISA).
Fives has committed itself to pay certain medical, dental, vision, life, disability and flexible spending claims under the plan.
You have the right to receive a copy of the full annual report, or any part thereof, on request. To obtain a copy of the report
write or call the office of Kay Pickart, plan administrator at 142 Doty Street, Fond du Lac, WI 54935 or call 920-906-2936 or
email kay.pickart@fivesgroup.com

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