Page 35 - Skyline Windows | 2022 Benefits Guide

To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
Special Enrollment
If you are declining enrollment for yourself or your dependents (including
your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in the plan, provided
that your request enrollment within 30 days after your other coverage ends (COBRA or state continuation coverage ends, divorce, legal separation, death, termination of employment or reduction in hours worked; or because the employer contributions cease). In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption or placement for adoption.
If you or your dependent lose coverage under a Medicaid Plan or Children’s Health Insurance Program (CHIP), or become eligible for group health plan premium assistance under a Medicaid Plan or under the CHIP, you may request enrollment within 60 days after coverage under the Medicaid or CHIP ends or within 60 after you or your dependent is determined to be eligible for state premium assistance under CHIP.
HIPAA Notice of Privacy Practices
Health Insurance Portability and Accountability Act (HIPAA) privacy rules require that Health Plans distribute a notice to participants of their privacy rights. This notice was provided to you upon your enrollment in the plan. You may also request a hard copy by contacting our HR Director, Dina Margolis, at: dmargolis@skylinewindows.com.
This Enrollment Guide represents a Summary of Material Modifications to the existing Summary Plan Descriptions available by contacting the HR Director, Dina Margolis, at: dmargolis@skylinewindows.com. In addition, this Guide highlights certain provisions of the welfare benefit plans available to eligible Skyline Windows employees (and dependents and/or beneficiaries) effective January 1, 2022. Complete details are in the respective Summary Plan Descriptions and plan documents. In case of a conflict between the information in this Enrollment Guide and the wording in either the official plan documents
or Summary Plan Descriptions, the plan documents and/or Summary Plan Descriptions always govern. The Company expects to continue these plans indefinitely but reserves the right to terminate, suspend, withdraw, amend or modify them at any time without prior notice to participants to the extent permitted by law. Any change, termination of benefits or increase in costs
to participants will be based solely on the decision of the Company and
may apply to active employees, employees on leave of absence, and former employees with coverage through COBRA. In addition, the tax treatment of these benefits is subject to change without notice, as determined by federal, state or local tax authorities.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
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