Page 34 - KIPP NYC 2022 Benfits Summary

For more information about this notice or your current prescription drug coverage:
Contact the Benefit Advocate Center at 844.905.0433 or bac.kippnyc@ajg.com.
NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through KIPP
NYC changes. You may also request a copy of this notice at any time.
For more information about your options under Medicare prescription drug coverage:
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov.
• Call your State Health Insurance Assistance Program
(see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.
• Call 800.MEDICARE (800.633.4227). TTY users should call 877.486.2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 800.772.1213 (TTY 800.325.0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Date: October 15, 2021
Name of Plan Sponsor: KIPP NYC
Contact–Position/Office: Don Cox, Benefits Manager
Plan Sponsor’s Address: 1501 Broadway, Suite 1000 New York, NY 10036
Our records show that you are eligible to participate in KIPP NYC Group Health Plan. A federal law called HIPAA requires that we notify you about two very important provisions in the plan. The first is your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. Second, this notice advises you of the plan’s preexisting condition exclusion rules that may temporarily exclude coverage for certain preexisting conditions that you or a member of your family may have.
Special Enrollment Provision
Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program):
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward 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).
Loss of Coverage for Medicaid or a State Children’s Health Insurance Program:
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption
If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
Eligibility for Medicaid or a State Children’s Health Insurance Program
If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.
To request special enrollment or to obtain more information about the plan’s special enrollment provisions, contact the Benefit Advocate Center at 844.905.0433.
Plan Sponsor’s Phone Number: 212.991.2610 x6022 Notice about Special Enrollment Rights In KIPP
NYC’S Group Health Plan
KIPP NYC
1501 Broadway, Suite 1000 New York, NY 10036
34 KIPP NYC PUBLIC SCHOOLS