Page 20 - 2016 WFF Guide 1
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The C ompany E mployee H ealth C are P lan
N otice of S pecial E nrollment R ights
I f you are d eclining enrollment for yourself or your d epend ents ( includ ing your
spouse) because of other health insurance or group health plan cov erage, you may be
able to later enroll yourself and your d epend ents in this plan if you or your d epend ents
lose eligibility for that other cov erage ( or if the employer stops contributing tow ard
your or your d epend ents’ other cov erage) .
L oss of eligibility includ es but is not limited to:
L oss of eligibility for cov erage as a result of ceasing to meet the plan’ s eligibility
req uirements ( i.e., legal separation, d iv orce, cessation of d epend ent status, d eath
of an employee, termination of employment, red uction in the number of hours of
employment) ;
L oss of H M O cov erage because the person no longer resid es or w ork s in the H M O
serv ice area and no other cov erage option is av ailable through the H M O plan
sponsor;
E limination of the cov erage option a person w as enrolled in, and another option is
not offered in its place;
F ailing to return from an F M L A leav e of absence; and
L oss of cov erage und er M ed icaid or the C hild ren’ s H ealth I nsurance P rogram
( C H I P ) .
U nless the ev ent giv ing rise to your special enrollment right is a loss of cov erage
und er M ed icaid or C H I P , you must req uest enrollment w ithin 3 0 d ays after your or
your d epend ent’ s( s’ ) other cov erage end s ( or after the employer that sponsors that
cov erage stops contributing tow ard the cov erage) .
I f the ev ent giv ing rise to your special enrollment right is a loss of cov erage und er
M ed icaid or C H I P , you may req uest enrollment und er this plan w ithin 6 0 d ays of the
d ate you or your d epend ent( s) lose such cov erage und er M ed icaid or C H I P . S imilarly, if
you or your d epend ent( s) become eligible for a state- granted premium subsid y tow ard
this plan, you may req uest enrollment und er this plan w ithin 6 0 d ays after the d ate
M ed icaid or C H I P d etermine that you or the d epend ent( s) q ualify for the subsid y.
I n ad d ition, if you hav e a new d epend ent as a result of marriage, birth, ad option,
or placement for ad option, you may be able to enroll yourself and your d epend ents.
H ow ev er, you must req uest enrollment w ithin 3 0 d ays after the marriage, birth,
ad option, or placement for ad option.
To req uest special enrollment or obtain more information, contact:
Beneits Administrator
3 1 4 .5 8 4 .6 6 2 9
* This notice is relev ant for healthcare cov erages subj ect to the H I P A A portability rules
The C ompany E mployee H ealth C are P lan
N otice of S pecial E nrollment R ights
I f you are d eclining enrollment for yourself or your d epend ents ( includ ing your
spouse) because of other health insurance or group health plan cov erage, you may be
able to later enroll yourself and your d epend ents in this plan if you or your d epend ents
lose eligibility for that other cov erage ( or if the employer stops contributing tow ard
your or your d epend ents’ other cov erage) .
L oss of eligibility includ es but is not limited to:
L oss of eligibility for cov erage as a result of ceasing to meet the plan’ s eligibility
req uirements ( i.e., legal separation, d iv orce, cessation of d epend ent status, d eath
of an employee, termination of employment, red uction in the number of hours of
employment) ;
L oss of H M O cov erage because the person no longer resid es or w ork s in the H M O
serv ice area and no other cov erage option is av ailable through the H M O plan
sponsor;
E limination of the cov erage option a person w as enrolled in, and another option is
not offered in its place;
F ailing to return from an F M L A leav e of absence; and
L oss of cov erage und er M ed icaid or the C hild ren’ s H ealth I nsurance P rogram
( C H I P ) .
U nless the ev ent giv ing rise to your special enrollment right is a loss of cov erage
und er M ed icaid or C H I P , you must req uest enrollment w ithin 3 0 d ays after your or
your d epend ent’ s( s’ ) other cov erage end s ( or after the employer that sponsors that
cov erage stops contributing tow ard the cov erage) .
I f the ev ent giv ing rise to your special enrollment right is a loss of cov erage und er
M ed icaid or C H I P , you may req uest enrollment und er this plan w ithin 6 0 d ays of the
d ate you or your d epend ent( s) lose such cov erage und er M ed icaid or C H I P . S imilarly, if
you or your d epend ent( s) become eligible for a state- granted premium subsid y tow ard
this plan, you may req uest enrollment und er this plan w ithin 6 0 d ays after the d ate
M ed icaid or C H I P d etermine that you or the d epend ent( s) q ualify for the subsid y.
I n ad d ition, if you hav e a new d epend ent as a result of marriage, birth, ad option,
or placement for ad option, you may be able to enroll yourself and your d epend ents.
H ow ev er, you must req uest enrollment w ithin 3 0 d ays after the marriage, birth,
ad option, or placement for ad option.
To req uest special enrollment or obtain more information, contact:
Beneits Administrator
3 1 4 .5 8 4 .6 6 2 9
* This notice is relev ant for healthcare cov erages subj ect to the H I P A A portability rules
