Page 13 - Open Sky BROCHURE - HOURLY 2021-2022

Regulatory Notices

 Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) –Provided separately
 New Health Insurance Marketplace Coverage Options and Your Health Coverage Notice
 Women's Health and Cancer Rights Act Notice
 Newborns' and Mothers’ Disclosure Notice
 Patient Protection Disclosure
 Notice of Special Enrollment Rights
 Qualified Medical Child Support Order Procedures
 HIPAA Privacy Practices
 General Notice of COBRA Continuation Coverage Rights
 Medicare Part D Credible Coverage Notice-If you (and/or your dependents) have Medicare or will become eligible for Medicare
in the next 12 months, a Federal law gives you more choice about your prescription drug coverage. Please see page 10 for more
details.

Women’s Health and Cancer Rights Act

The Women’s Health and Cancer Rights Act (WHCRA) of 1998, requires group health plans to make certain benefits
available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patients
benefits 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

Our plan complies with these requirements. Benefits for these items generally are comparable to those provided under
our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is
appropriate following mastectomy is a matter to be determined by the patient and the physician. Our plan neither
imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending
providers to provide care inconsistent with these requirements. If you would like more information about WHCRA
required coverage, you can contact the Plan Administrator.

Newborns’ and Mothers’ Disclosure Notice

MATERNITY BENEFITS
Under Federal and state law you have certain rights and protections regarding your Maternity benefits under the Plan.

Under federal law known as the “Newborns’ and Mothers’ Health Protection Act of 1996” (Newborns’ Act) group
health plans and health insurance issuers generally may not restrict benefits for any hospital length of stay in connection
with childbirth for the Mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours
following a cesarean section.

However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans
and issuers may not, under federal law, require that a provider obtain Authorization from the plan or the issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).

Under California law, if your Plan provides benefits for obstetrical services your benefits will include coverage for
postpartum services. Coverage will include benefits for inpatient care and a home visit or visits, which shall be in
accordance with the medical criteria, outlined in the most current version of or an official update to the “Guidelines for
Perinatal Care" prepared by the American Academy of Pediatrics and the American College of Obstetricians and

Gynecologists or the "Standards for Obstetric-Gynecologic Services" prepared by the American College of Obstetricians
and Gynecologists. Coverage for obstetrical services as an inpatient in a general Hospital or obstetrical services by a