Page 140 - 2021 Medical Plan SPD

Can I provide additional information about my claim? Yes, you may give us additional information
supporting your claim. Send the information to the address provided in the initial denial letter or
Explanation of Benefits.
Can I request copies of information relating to my claim? Yes. There is no cost to you for these
copies. Send your request to the address provided in the initial denial letter or Explanation of Benefits.
What happens if I don't agree with the outcome of my appeal? If you appeal, the Claims Fiduciary will
review its decision. The Claims Fiduciary will also send you its written decision within the time allowed. If
you do not agree with the decision, you may be able to request an external review of your claim by an
independent third party. If so, the Claims Fiduciary will review the denial and issue a final decision.

If I need additional help, what should I do? For questions on your appeal rights, you may call the
Claims Administrator at the number listed on your health plan ID card for assistance. You may also
contact the support groups listed below.
Are verbal translation services available to me during an appeal? Yes. Contact the Claims
Administrator at the number listed on your health plan ID card. Ask for verbal translation services for your
questions.
Is there other help available to me? For questions about appeal rights, an unfavorable benefit decision,
or for help, you may also contact the Employee Benefits Security Administration at 1-866-444-EBSA
(3272). Your state consumer assistance program may also be able to help you.

If your plan includes coverage for Mental Health or Substance Use,
the following applies:

Mental Health/Substance Use Disorder Parity
Effective for grandfathered and non-grandfathered large group Plans that are new or renewing on or after
July 1, 2010, Benefits are subject to final regulations supporting the Mental Health Parity and Addiction
Equity Act of 2008 (MHPAEA). Benefits for mental health conditions and substance use disorder
conditions that are Covered Health Care Services under the Plan must be treated in the same manner
and provided at the same level as Covered Health Care Services for the treatment of other Sickness or
Injury. Benefits for Mental Health Services and Substance-Related and Addictive Disorders Services are
not subject to any annual maximum benefit limit (including any day, visit or dollar limit).
MHPAEA requires that the financial requirements for coinsurance and copayments for mental health and
substance use disorder conditions must be no more restrictive than those coinsurance and copayment
requirements for substantially all medical/surgical benefits. MHPAEA requires specific testing to be
applied to classifications of benefits to determine the impact of these financial requirements on mental
health and substance use disorder benefits. Based upon the results of that testing, it is possible that
coinsurance or copayments that apply to mental health conditions and substance use disorder conditions
in your benefit plan may be reduced.

6 Federal Notice