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IMPORTANT BENEFIT ELECTION INFORMATION AND REQUIRED NOTICES
Enclosed in this packet is important benefit information regarding the Milo’s Hamburgers open enrollment period, election options, and plan details. Also included are the legal notices listed below. Milo’s Hamburgers is providing these important notices to you as required by federal laws governing benefits administration. The notices in this package describe important rights that you have under the terms of the Milo’s Hamburgers Group Health Plan. If you have any questions or need additional information regarding these notices you can contact:
Your Employer Representative
Tammy Walters
*****.*@***************.***
or by mail at
828 Columbiana Road
Birmingham, AL 35209
The following notices are included in this communication in this order:
Summary of Benefits and Coverage (SBC)
WHCRA Notice (Women’s Health and Cancer Rights Act)
CHIPRA Notice (Children’s Health Insurance Program Reauthorization Act)
HIPAA Special Enrollment Rights Notice
Health Insurance Marketplace / Exchange Notice
Medicare D Creditable Coverage Notice (see box below for more information) If you or your dependents have Medicare or will become eligible for Medicare in the next 12 months, a Federal law, which started in 2006, gives you more choices about your prescription drug coverage. Please see notice for more details. Notice of Women’s Health and Cancer Rights Act of 1998 If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
All stages of reconstruction of the breast on which the mastectomy was performed
Surgery and reconstruction of the other breast to produce a symmetrical appearance
Prostheses
Treatment of physical complications of the mastectomy, including lymphedema These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.
If you would like more information on WHCRA benefits, contact Tammy Walters at 205-***-****. Privacy Notice
The privacy rules under the Health Insurance Portability and Accountability Act (HIPAA) require MILO’S HAMBURGERS (the “Plan”) to periodically send a reminder to participants about the availability of the Plan’s Privacy Notice and how to obtain that notice. The Privacy Notice explains participants’ rights and the Plan’s legal duties with respect to protected health information (PHI) and how the Plan may use and disclose PHI. To obtain a copy of the Privacy Notice, contact Tammy Walters.
HIPAA Special Enrollment Notice
This notice is being provided to make certain that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive health insurance coverage at this time. If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption.
To request special enrollment or obtain more information, please contact Tammy Walters at 205-***-****. Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1 877 Required Legal Notices
KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1 866 444 EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2015. Contact your State for more information on eligibility –
ALABAMA – Medicaid GEORGIA – Medicaid
Website: www.myalhipp.com
Phone: 1-855-***-****
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 404-***-****
ALASKA – Medicaid INDIANA – Medicaid
Website:
http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-***-****
Phone (Anchorage): 907-***-****
Website: http://www.in.gov/fssa
Phone: 1-800-***-****
COLORADO – Medicaid IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-***-****
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-***-****
FLORIDA – Medicaid KANSAS – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-***-****
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-***-****
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-***-****
Website:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-***-****
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-***-****
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-***-****
CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-***-****
MAINE – Medicaid NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public
assistance/index.html
Phone: 1-800-***-****
TTY 1-800-***-****
Website:
http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-***-****
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid Website: http://www.mass.gov/MassHealth
Phone: 1-800-***-****
Website: http://www.ncdhhs.gov/dma
Phone: 919-***-****
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid
Website: http://www.dhs.state.mn.us/id_006254
Click on Health Care, then Medical Assistance
Phone: 1-800-***-****
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-***-****
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.ht m
Phone: 573-***-****
Website: http://www.insureoklahoma.org
Phone: 1-888-***-****
MONTANA – Medicaid OREGON – Medicaid
Website: http://medicaid.mt.gov/member
Phone: 1-800-***-****
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-***-****
NEBRASKA – Medicaid PENNSYLVANIA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-855-***-****
Website: http://www.dhs.state.pa.us/hipp
Phone: 1-800-***-****
NEVADA – Medicaid RHODE ISLAND – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-***-****
Website: http://www.eohhs.ri.gov/
Phone: 401-***-****
SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP Website: http://www.scdhhs.gov
Phone: 1-888-***-****
Medicaid Website:
http://www.coverva.org/programs_premium_assistance. cfm
Medicaid Phone: 1-800-***-****
CHIP Website:
http://www.coverva.org/programs_premium_assistance. cfm
CHIP Phone: 1-855-***-****
SOUTH DAKOTA Medicaid WASHINGTON – Medicaid
Website: http://dss.sd.gov
Phone: 1-888-***-****
Website:
http://www.hca.wa.gov/medicaid/premiumpymt/pages/
index.aspx
Phone: 1-800-***-**** ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-***-****
Website:
http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/
Pages/default.aspx
Phone: 1-877-***-****, HMS Third Party Liability
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Website:
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-866-***-****
Website:
https://www.dhs.wisconsin.gov/badgercareplus/p
10095.htm
Phone: 1-800-***-****
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-***-****
Website: https://wyequalitycare.acs inc.com/
Phone: 307-***-****
To see if any other states have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov
1 866 444 EBSA (327*-*-***-*** 2323, Menu Option 4, Ext. 61565 OMB Control Number 1210 0137 (expires 10/31/2016)
Important Notice from MILO’S HAMBURGERS About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with MILO’S HAMBURGERS and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. MILO’S HAMBURGERS has determined that the prescription drug coverage offered by the MILO’S HAMBURGERS Group Health Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will be able to get this coverage back only at the next open enrollment period. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with MILO’S HAMBURGERS and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare
& You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help
Call 1-800-MEDICARE (1-800-***-****). TTY users should call 1-877-***-****. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-***-**** (TTY 1-800-***-****). Date: October 2016
Plan Year: 2016 - 2017
Name of Entity/Sender: Tammy Walters
Contact--Position/Office: Payroll Manager
Address: 828 Columbiana Road
Phone Number: 205-***-****
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
Contact this candidate