Page 25 - 2016 WFF Guide 1
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Alternate Recipients Under Qualiied Medical Child Support Orders. A child of the W omen’ s H ealth and
covered employee or former employee who is receiving beneits under the plan C ancer R ights N otice
pursuant to a Qualiied Medical Child Support Order (QMCSO) received by the Plan
A d ministrator d uring the employee’ s period of employment w ith the employer is The C ompany E mployee H ealth C are P lan
entitled the same rights und er C O B R A as an eligible child of the cov ered employee, is req uired by law to prov id e you w ith the
regard less of w hether that child w ould otherw ise be consid ered a d epend ent. B e sure follow ing notice:
to promptly notify the P lan A d ministrator or its d esignee if you need to mak e a change
to your COBRA coverage. The Plan Administrator or its designee must be notiied in The W omen’ s H ealth and C ancer R ights
w riting w ithin 3 0 d ays of the d ate you w ish to mak e such a change. S ee the rules in A ct of 1 9 9 8 ( “ W H C R A ” ) prov id es certain
the box abov e, und er the head ing entitled , “ N otice P roced ures, ” for an ex planation protections for ind iv id uals receiv ing
regard ing how your notice should be mad e. mastectomy-related beneits. Coverage
w ill be prov id ed in a manner d etermined
A re There O ther C ov erage O ptions B esid es C obra C ontinuation in consultation w ith the attend ing
C ov erage? physician and the patient for:
Y es. I nstead of enrolling in C O B R A continuation cov erage, there may be other A ll stages of reconstruction of the
cov erage options for you and your family through the H ealth I nsurance M ark etplace, breast on w hich the mastectomy w as
performed
M ed icaid , or other group health plan cov erage options ( such as a spouse’ s plan)
through w hat is called a “ special enrollment period .” S ome of these options may cost S urgery and reconstruction of
the other breast to prod uce a
less than C O B R A continuation cov erage. Y ou can learn more about many of these symmetrical appearance
options at w w w .healthcare.gov .
P rostheses
I f Y ou H av e Q uestions Treatment of physical complications
Q uestions concerning your P lan or your C O B R A continuation cov erage rights should of the mastectomy, includ ing
lymphed emas
be addressed to the contact or contacts identiied below. For more information
about your rights und er E R I S A , includ ing C O B R A , the H ealth I nsurance P ortability The C ompany E mployee H ealth C are
or A ccountability A ct ( H I P A A ) , and other law s affecting group health plans, contact P lan prov id e( s) med ical cov erage for
the nearest Regional or District Ofice of the U.S. Department of Labor’s Employee mastectomies and the related proced ures
Beneits Security Administration (EBSA). Addresses and phone numbers of Regional listed abov e, subj ect to the same
and District EBSA Ofices are available through EBSA’s Web site at www.dol.gov/ebsa. d ed uctibles and coinsurance applicable
to other medical and surgical beneits
K eep Y our P lan I nformed of A d d ress C hanges
prov id ed und er this plan.
To protect your family’ s rights, let the P lan A d ministrator k now about any changes in
the ad d resses s of family members. Y ou should also k eep a copy, for your record s, of I f you w ould lik e more information on
any notices you send to the P lan A d ministrator. WHCRA beneits, please refer to your
S ummary P lan D escription or contact
P lan C ontact I nformation your P lan A d ministrator.
Beneits Administrator
3 1 4 .5 8 4 .6 6 2 9
O M B C ontrol N umber 1 2 1 0 - 0 1 2 3 ( ex pires 1 0 / 3 1 / 2 0 1 6 )
2016 Open Enrollment
Alternate Recipients Under Qualiied Medical Child Support Orders. A child of the W omen’ s H ealth and
covered employee or former employee who is receiving beneits under the plan C ancer R ights N otice
pursuant to a Qualiied Medical Child Support Order (QMCSO) received by the Plan
A d ministrator d uring the employee’ s period of employment w ith the employer is The C ompany E mployee H ealth C are P lan
entitled the same rights und er C O B R A as an eligible child of the cov ered employee, is req uired by law to prov id e you w ith the
regard less of w hether that child w ould otherw ise be consid ered a d epend ent. B e sure follow ing notice:
to promptly notify the P lan A d ministrator or its d esignee if you need to mak e a change
to your COBRA coverage. The Plan Administrator or its designee must be notiied in The W omen’ s H ealth and C ancer R ights
w riting w ithin 3 0 d ays of the d ate you w ish to mak e such a change. S ee the rules in A ct of 1 9 9 8 ( “ W H C R A ” ) prov id es certain
the box abov e, und er the head ing entitled , “ N otice P roced ures, ” for an ex planation protections for ind iv id uals receiv ing
regard ing how your notice should be mad e. mastectomy-related beneits. Coverage
w ill be prov id ed in a manner d etermined
A re There O ther C ov erage O ptions B esid es C obra C ontinuation in consultation w ith the attend ing
C ov erage? physician and the patient for:
Y es. I nstead of enrolling in C O B R A continuation cov erage, there may be other A ll stages of reconstruction of the
cov erage options for you and your family through the H ealth I nsurance M ark etplace, breast on w hich the mastectomy w as
performed
M ed icaid , or other group health plan cov erage options ( such as a spouse’ s plan)
through w hat is called a “ special enrollment period .” S ome of these options may cost S urgery and reconstruction of
the other breast to prod uce a
less than C O B R A continuation cov erage. Y ou can learn more about many of these symmetrical appearance
options at w w w .healthcare.gov .
P rostheses
I f Y ou H av e Q uestions Treatment of physical complications
Q uestions concerning your P lan or your C O B R A continuation cov erage rights should of the mastectomy, includ ing
lymphed emas
be addressed to the contact or contacts identiied below. For more information
about your rights und er E R I S A , includ ing C O B R A , the H ealth I nsurance P ortability The C ompany E mployee H ealth C are
or A ccountability A ct ( H I P A A ) , and other law s affecting group health plans, contact P lan prov id e( s) med ical cov erage for
the nearest Regional or District Ofice of the U.S. Department of Labor’s Employee mastectomies and the related proced ures
Beneits Security Administration (EBSA). Addresses and phone numbers of Regional listed abov e, subj ect to the same
and District EBSA Ofices are available through EBSA’s Web site at www.dol.gov/ebsa. d ed uctibles and coinsurance applicable
to other medical and surgical beneits
K eep Y our P lan I nformed of A d d ress C hanges
prov id ed und er this plan.
To protect your family’ s rights, let the P lan A d ministrator k now about any changes in
the ad d resses s of family members. Y ou should also k eep a copy, for your record s, of I f you w ould lik e more information on
any notices you send to the P lan A d ministrator. WHCRA beneits, please refer to your
S ummary P lan D escription or contact
P lan C ontact I nformation your P lan A d ministrator.
Beneits Administrator
3 1 4 .5 8 4 .6 6 2 9
O M B C ontrol N umber 1 2 1 0 - 0 1 2 3 ( ex pires 1 0 / 3 1 / 2 0 1 6 )
2016 Open Enrollment
