Page 25 - Technip Energies 2022 benefits guide

that request health information may violate the collection • If you or your dependents become eligible for a state
prohibition unless they fit within an exception to the premium assistance subsidy through Medicaid or a state
prohibition for inadvertent acquisition of such information. CHIP with respect to coverage under this plan and you
This exception applies if the request does not violate any request enrollment within 60 days or any longer period
laws, does not ask for genetic information and includes that applies under the plan after the determination of
a warning against providing genetic information in any eligibility for such assistance.
responses.
Note: The 60-day period for requesting enrollment applies
only in these last two listed circumstances relating to
Patient Protection Disclosure Medicaid and state CHIP. As described above, a 31-day

The Company generally allows the designation of a period applies to most special enrollments.
primary care provider. You have the right to designate any As stated earlier in this notice, a special enrollment
primary care provider who participates in our network and opportunity may be available in the future if you or your
who is available to accept you or your family members. dependents lose other coverage. This special enrollment

For children, you may designate a pediatrician as the opportunity will not be available when other coverage
primary care provider. ends, however, unless you provide a written statement
now explaining the reason that you are declining coverage
You do not need prior authorization from the Company or for yourself or your dependent(s). Failing to accurately
from any other person (including a primary care provider) complete and return this form for each person for whom
in order to obtain access to obstetrical or gynecological you are declining coverage may eliminate this special
care from a health care professional in our network who enrollment opportunity for the person(s) for whom a
specializes in obstetrics or gynecology. The health care statement is not completed, even if other coverage is
professional, however, may be required to comply with currently in effect and is later lost. In addition, unless you
certain procedures, including obtaining prior authorization indicate in the statement that you are declining coverage
for certain services, following a pre-approved treatment because other coverage is in effect, you may not have this
plan, or procedures for making referrals. For a list of special enrollment opportunity for the person(s) covered
participating health care professionals who specialize in by the statement. (See the paragraphs above, however,
obstetrics or gynecology, contact the Plan Administrator or regarding enrollment in the event of marriage, birth,
issuer noted at the front of the Required Notices section. adoption, placement for adoption, loss of eligibility for
Medicaid or a state CHIP, and gaining eligibility for a state
HIPAA Notice of Special Enrollment Rights premium assistance subsidy through Medicaid or a state

If you are declining enrollment for yourself or your CHIP.)
dependents (including your spouse) because of other To request special enrollment or obtain more information,
health insurance or group health plan coverage, you may contact your Plan Administrator.
be able to enroll yourself or your dependents in this plan
if you or your dependents lose eligibility for that other Notice of Availability of Summary of Benefits
coverage (or if the employer stops contributing towards
your or your dependents’ other coverage). However, you and Coverage (SBC)
must request enrollment within 31 days after your or your As an employee or retiree, the health benefits available
dependents’ other coverage ends (or after the employer to you represent a significant component of your
stops contributing toward the other coverage). compensation package. They also provide important
protection for you and your family in the case of illness or
In addition, if you have a new dependent as result of injury. The Company offers a series of health coverage
marriage, birth, adoption, or placement for adoption, you options. Choosing your health insurance coverage is an
may be able to enroll yourself and your dependents. important decision. To help you make an informed choice,
However, you must request enrollment within 31 days after The Company makes available a Summary of Benefits and
the marriage, birth, adoption, or placement for adoption. Coverage (SBC), which summarizes important information

Special enrollment rights also may exist in the following about your health coverage options in a standard format,
circumstances to help you compare. The SBCs are only a summary.
You should consult The Company’s Summary Plan
• If you or your dependents experience a loss of eligibility Descriptions and/or Medical Benefit Booklet to determine
for Medicaid or a state Children’s Health Insurance the governing contractual provisions of the coverage. A
Program (CHIP) coverage and you request enrollment paper copy is also available, free of charge, by contacting
within 60 days after that coverage ends; or your Plan Administrator.

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