Page 30 - 2019 Benefit Guide Non-CA

IMPORTANT NOTICES

If the breach involves 500 or more residents of a » Elimination of the coverage option a person was
state, the Plan will notify prominent media outlets in enrolled in, and another option is not offered in its
the state. The Plan will maintain a log of security place;
breaches and will report this information to HHS on an » Failing to return from an FMLA leave of absence;
annual basis. Immediate reporting from the Plan to and
HHS is required if a security breach involves 500 or
more people. » Loss of coverage under Medicaid or the Children’s
Health Insurance Program (CHIP).
Contact Person for Information, or to Submit a Unless the event giving rise to your special enrollment
Complaint right is a loss of coverage under Medicaid or CHIP,
If you have questions about this Notice please you must request enrollment by the HIPAA Special
contact the Plan’s Privacy Official or Deputy Privacy Enrollment Deadline after your or your dependent’s(s’)
Official(s) (see first page). If you have any other coverage ends (or after the employer that
complaints about the Plan’s privacy practices, sponsors that coverage stops contributing toward the
handling of your PHI, or breach notification process, coverage).
please contact the Privacy Official or an authorized If the event giving rise to your special enrollment right
Deputy Privacy Official. is a loss of cover- age under Medicaid or the CHIP,
you may request enrollment under this plan within 60
Organized Health Care Arrangement days of the date you or your dependent(s) lose such
Designation coverage under Medicaid or CHIP. Similarly, if you or
The Plan participates in what the federal privacy rules your dependent(s) become eligible for a state-
call an “Organized Health Care Arrangement.” The granted premium subsidy towards this plan, you may
purpose of that participation is that it allows PHI to be request enrollment under this plan within 60 days
shared between the members of the Arrangement, after the date Medicaid or CHIP determine that you
without authorization by the persons whose PHI is or the dependent(s) qualify for the subsidy.
shared, for health care operations. Primarily, the In addition, if you have a new dependent as a result
designation is useful to the Plan because it allows the of marriage, birth, adoption, or placement for
insurers who participate in the Arrangement to share adoption, you may be able to enroll yourself and
PHI with the Plan for purposes such as shopping for your dependents. However, you must request
other insurance bids. enrollment by the HIPAA Special Enrollment Deadline,
HIPAA Notice of Special Enrollment Rights after the marriage, birth, adoption, or placement for
adoption. To request special enrollment or obtain
If you are declining enrollment for yourself or your more in- formation, contact the Plan Administrator.
dependents (including your spouse) because of Note: Additional information may be required if the
other health insurance or group health plan plan requires that persons declining coverage under
coverage, you may be able to later enroll yourself the plan state, in writing, the reason(s) for declining
and your dependents in this plan if you or your coverage.
dependents lose eligibility for that other coverage (or
if the employer stops contributing towards your or
your dependents’ other coverage). Loss of eligibility
includes but is not limited to:
» Loss of eligibility for coverage as a result of ceasing
to meet the plan’s eligibility requirements (i.e., legal
separation, divorce, cessation of dependent
status, death of an employee, termination of
employment, reduction in the number of hours of
employment);
» Loss of HMO coverage because the person no
longer resides or works in the HMO service area and
no other coverage option is available through the
HMO plan sponsor;

30