ComplianceNotices
Thefollowingnoticesprovideimportantinformationaboutthegrouphealthplanprovidedby youremployer.Pleasereadtheattachednoticescarefullyandkeepacopyforyourrecords.
Ifyouhaveanyquestionsregardinganyofthesenotices,pleasecontact: GeneralContact:KirstenHarwood–HumanResources
Phone:317-466-9520
Email:kharwood@eticagroup.com
MailingAddress:8720CastleCreekParkwayE.Dr.Suite400
ComplianceNotices
NoticeofSpecialEnrollmentRights
Ifyouaredecliningenrollmentforyourselforyourdependents(includingyourspouse)becauseofotherhealthinsuranceor grouphealthplancoverage,youmaybeabletoenrollyourselfandyourdependentsinthisplanifyouoryourdependents loseeligibilityforthatothercoverage(oriftheemployerstopscontributingtowardyouroryourdependents’othercoverage). However,youmustrequestenrollmentwithin30daysafteryouroryourdependents’othercoverageends(orafterthe employerstopscontributingtowardtheothercoverage).Inaddition,ifyouhaveanewdependentasaresultofmarriage, birth,adoption,orplacementforadoption,youmaybeabletoenrollyourselfandyourdependents.However,youmust requestenrollmentwithin30daysafterthemarriage,birth,adoption,orplacementforadoption.
Ifyouaredecliningenrollmentforyourselforyourdependents(includingyourspouse)whilecoverageunderMedicaidora stateChildren’sHealthInsuranceProgram(CHIP)isineffect,youmaybeabletoenrollyourselfandyourdependentsin thisplanifyouoryourdependentsloseeligibilityforthatothercoverage.However,youmustrequestenrollmentwithin60 daysafteryouroryourdependents’MedicaidorCHIPcoverageends.Ifyouoryourdependents(includingyourspouse) becomeeligibleforastatepremiumassistancesubsidyfromMedicaidoraCHIPprogramwithrespecttocoverageunder thisplan,youmaybeabletoenrollyourselfandyourdependents(includingyourspouse)inthisplan.However,youmust requestenrollmentwithin60daysafteryouoryourdependentsbecomeeligibleforthepremiumassistance.
NoticeofPatientProtection
Ifyourhealthplangenerallyrequiresthedesignationofaprimarycareprovider,youhavetherighttodesignateanyprimary careproviderwhoparticipatesinournetworkandwhoisavailabletoacceptyouoryourfamilymembers.Forchildren,you maydesignateapediatricianastheprimarycareprovider.Untilyoumakethisdesignation,thehealthplangenerallymay designateoneforyou.Forinformationonhowtoselectaprimarycareprovider,andforalistoftheparticipatingprimary careproviders,contactyourplanadministratororyourHumanResourcesDepartment.
Youdonotneedpriorauthorizationfromthehealthplanorfromanyotherperson(includingaprimarycareprovider)in ordertoobtainaccesstoobstetricalorgynecologicalcarefromahealthcareprofessionalinournetworkwhospecializesin obstetricsorgynecology.Thehealthcareprofessional,however,mayberequiredtocomplywithcertainprocedures, includingobtainingpriorauthorizationforcertainservices,followingapre-approvedtreatmentplan,orproceduresfor makingreferrals.Foralistofparticipatinghealthcareprofessionalswhospecializeinobstetricsorgynecology,contactyour planadministratororHumanResourcesDepartment.
Women’sHealthandCancerRightsActNotice
Ifyouhavehadoraregoingtohaveamastectomy,youmaybeentitledtocertainbenefitsundertheWomen’sHealthand CancerRightsActof1998(WHCRA).Forindividualsreceivingmastectomy-relatedbenefits,coveragewillbeprovidedina mannerdeterminedinconsultationwiththeattendingphysicianandthepatient,for:
•Allstagesofreconstructionofthebreastonwhichthemastectomywasperformed;
•Surgeryandreconstructionoftheotherbreasttoproduceasymmetricalappearance;
•Prostheses;and
•Treatmentofphysicalcomplicationsofthemastectomy,includinglymphedema.
Thesebenefitswillbeprovidedsubjecttothesamedeductiblesandcoinsuranceapplicabletoothermedicalandsurgical benefitsprovidedunderthisplan.IfyouwouldlikemoreinformationonWHCRAbenefits,contactthePlanAdministrator.
Newborns’andMothers’HealthProtectionActNotice
Grouphealthplansandhealthinsuranceissuersgenerallymaynot,underFederallaw,restrictbenefitsforanyhospital lengthofstayinconnectionwithchildbirthforthemotherornewbornchildtolessthan48hoursfollowingavaginaldelivery, orlessthan96hoursfollowingacesareansection.However,Federallawgenerallydoesnotprohibitthemother'sor newborn'sattendingprovider,afterconsultingwiththemother,fromdischargingthemotherorhernewbornearlierthan48
4 ComplianceNotices
hours(or96hoursasapplicable).Inanycase,plansandissuersmaynot,underFederallaw,requirethataproviderobtain authorizationfromtheplanortheinsuranceissuerforprescribingalengthofstaynotinexcessof48hours(or96hours).
Michelle’sLawNotice
Michelle’sLawwassignedintolaweffectiveJanuary1,2010.Thislawgenerallyallowsseriouslyillorinjuredfulltime collegestudents,whoarecoveredundertheirparent’shealthinsuranceplan,totakeuptooneyearofmedicallynecessary leaveofabsenceiftheleavenormallywouldcausethedependentchildtoloseeligibilityforcoverageundertheplandueto lossofstudentstatus.FortheMichelle’sLawextensionofeligibilitytoapply,adependentchild’streatingphysicianmust providewrittencertificationofmedicalnecessity(i.e.,certificationthatthedependentchildsuffersfromaseriousillnessor injurythatnecessitatestheleaveofabsenceorotherenrollmentchangethatwouldotherwisecauselossofeligibility).
*UnderthePatientProtectionandAffordableCareAct,grouphealthplansarerequiredtooffercoveragetodependent childrenuptoage26,regardlessofstudentstatus.
HIPAANoticeofPrivacyPractices
TheHealthInsurancePortabilityandAccountabilityActof1996("HIPAA")requiresthatwemaintaintheprivacyofprotected healthinformation,givenoticeofourlegaldutiesandprivacypracticesregardinghealthinformationaboutyouandfollowthe termsofournoticecurrentlyineffect.Participantsininsuredgrouphealthplansmayalsoreceiveanoticeofprivacy practicesfromthoseplans.YoumayrequestacopyofthecurrentPrivacyPractices,explaininghowmedicalinformation aboutyoumaybeusedanddisclosedandhowyoucangetaccesstothisinformation.
AsRequiredbyLaw.WewilldiscloseHealthInformationwhenrequiredtodosobyinternational,federal,stateorlocallaw. Youhavetherighttoinspectandcopy,righttoanelectroniccopyofelectronicmedicalrecords,righttogetnoticeofa breach,righttoamend,righttoanaccountingofdisclosures,righttorequestrestrictions,righttorequestconfidential communications,righttoapapercopyofthisnoticeandtherighttofileacomplaintifyoubelieveyourprivacyrightshave beenviolated.
GeneticInformationNondiscriminationActof2008(GINA)
TheGeneticInformationNondiscriminationActof2008(“GINA”)prohibitsthePlanfromdiscriminatingagainstindividualson thebasisofgeneticinformationinprovidinganythebenefitsunderincludedbenefitplans.GINAgenerally:
•ProhibitsthePlanfromadjustingpremiumorcontributionamountsforagrouponthebasisofgeneticinformation;
•ProhibitsthePlanfromrequestingormandatingthatanindividualorfamilymemberofanindividualundergoagenetic test,providedthatsuchprohibitiondoesnotlimittheauthorityofahealthcareprofessionaltorequestanindividualto undergoagenetictest,orprecludeagrouphealthplanfromobtainingorusingtheresultsofagenetictestinmakinga determinationregardingpayment;
•AllowsthePlantorequest,butnotmandate,thataparticipantorbeneficiaryundergoagenetictestforresearch purposesifthePlandoesnotusetheinformationforunderwritingpurposesandmeetscertaindisclosurerequirements; and
•ProhibitsthePlanfromrequesting,requiring,orpurchasinggeneticinformationforunderwritingpurposes,orwithrespect toanyindividualinadvanceoforinconnectionwithsuchindividual’senrollment.
MentalHealthParityActNotice
TheMentalHealthParityAct(“MHPA”)requiresthattheannualorlifetimedollarlimitsonmentalhealthbenefitsmaynotbe lowerthananysuchdollarlimitsforhealthandsurgicalbenefitsofferedbyagrouphealthplanorhealthinsuranceissuer offeringcoverageinconnectionwithagrouphealthplan.ThelifetimelimitceasedtoapplyeffectiveJanuary1,2011andthe annuallimitceasedtoapplyeffectiveJanuary1,2014.Beginningwiththe2010planyear,federallawalsowillrequirethat plansprovidingbothhealth/surgicalandmentalhealthbenefitsmaynotimposemorerestrictivefinancialrequirements(such asdeductiblesandcopayments)andtreatmentlimitations(suchaslimitsondaysofcoverage)onmentalhealthbenefits thanareimposedonhealth/surgicalbenefits.
ComplianceNotices
AQualifiedMedicalChildSupportOrder(QMCSO)isacourtorderoranorderissuedbyastateadministrativeagencyin accordancewithfederalandstatelawsthatrequiresanalternatebeneficiary(forexample,achildorstepchild)tobe coveredbyaplanparticipant’sgrouphealthplan.ThePlanhonorsQMCSOsthatmeetthelegalrequirementsforsuch orders.ItisimportanttonotethataQMCSOcannotrequireaplantoprovideatypeorformofbenefit,oranoption,thatis notcurrentlyavailablefromtheplantowhichtheorderisdirected,unlessreceivingthisbenefitoroptionisnecessaryto meettherequirementsoftheSocialSecurityAct,whichrelatestotheenforcementofstatechildsupportlawsand reimbursementofMedicaid.AQMCSOmustbeprovidedtothePlanAdministratortodetermineifitmeetsthelegal requirementsforaQMCSO.Ifitdoes,thealternatebeneficiaryisconsideredabeneficiaryforthepurposesofERISAandis enrolledasadependentoftheemployeeparticipant.IfthePlanAdministratorreceivesamedicalchildsupportorderthat relatestoyou,youwillbenotifiedandtheninformedofthedecisionastowhethertheorderisqualified.
UniformedServicesEmploymentandReemploymentRightsAct(USERRA)
Continuationandreinstatementrightsmayalsobeavailableifyouareabsentfromemploymentduetoserviceinthe uniformedservicespursuanttotheUniformedServicesEmploymentandReemploymentRightsActof1994(USERRA).If youtakeleaveunderUSERRA,totheextentrequiredbyUSERRA,yourEmployermaycontinuetomaintainyourbenefits onthesametermsandconditionsasifyouwerestillanactiveemployee.
EmployeesgoingintoorreturningfromserviceintheuniformedservicesmayhavePlanrightsmandatedbyUSERRA. TheserightsapplyonlytoemployeesandtheirdependentscoveredunderthePlanbeforetheemployeeleftformilitary service.TobeentitledtoUSERRArights,theemployeemustgivetheemployeradvancednoticeoftheemployee’sabsence fromemploymentforuniformedservice,unlessprecludedbymilitarynecessityorifitisotherwiseimpossibleor unreasonableunderallthecircumstances.Additionally,subjecttocertainexceptions,theemployee’sabsencefromwork maynotexceedfiveyears.
USERRArightsincludeupto24monthsofcontinuedhealthcarecoverage.Forperiodsofleavelessthan31days,the employeeonlyneedstopayhisorhernormalportionofthepremium.Forperiodsofleave31daysormore,coveragewill onlybeextendeduponpaymentoftheentirecostofcoverageplusareasonableadministrativefee.
IfyoucomplywithUSERRAuponreturningtoactiveemploymentaftermilitaryservice,youmayre-enrollyourselfandyour eligibledependentsinhealthcoverageimmediatelyuponreturningtoactiveemployment,evenifyouandyoureligible dependentsdidnotelectUSERRAcontinuationcoverageduringyourmilitaryservice.Reinstatementwilloccurwithoutany waitingperiodsorpre-existingconditionexclusions,exceptforillnessesorinjuriesconnectedtothemilitaryservice.
USERRArightsterminateiftheemployee’sdischargefromtheuniformedservicewasaresultof“dishonorable”orother undesirableconduct,theemployeefailstoreportbacktoworkorapplyforreemploymentwithinthetimeperiodrequired underUSERRA,oriftheemployeefailstopaycoveragepremiums.
ThetimeperiodswithinwhichtoelectandpayforUSERRAcontinuationofcoverageshallbethesametimeperiodswithin whichtoelectandpayforCOBRAcoverageunderthePlan.IfbothUSERRAandCOBRAapply,anelectionfor continuationcoveragewillbeanelectiontotakeconcurrentCOBRA/USERRAcoverage.Notealsothatstatelawmay providecontinuationand/orconversioncoverage.
ComplianceNotices
PremiumAssistanceUnderMedicaidandtheChildren’sHealthInsuranceProgram(CHIP) IfyouoryourchildrenareeligibleforMedicaidorCHIPandyou’reeligibleforhealthcoveragefromyouremployer,your statemayhaveapremiumassistanceprogramthatcanhelppayforcoverage,usingfundsfromtheirMedicaidorCHIP programs.Ifyouoryourchildrenaren’teligibleforMedicaidorCHIP,youwon’tbeeligibleforthesepremiumassistance programsbutyoumaybeabletobuyindividualinsurancecoveragethroughtheHealthInsuranceMarketplace.Formore information,visitwww.healthcare.gov.
IfyouoryourdependentsarealreadyenrolledinMedicaidorCHIPandyouliveinaStatelistedbelow,contactyourState MedicaidorCHIPofficetofindoutifpremiumassistanceisavailable.
IfyouoryourdependentsareNOTcurrentlyenrolledinMedicaidorCHIP,andyouthinkyouoranyofyourdependents mightbeeligibleforeitheroftheseprograms,contactyourStateMedicaidorCHIPofficeordial1-877-KIDSNOWor www.insurekidsnow.govtofindouthowtoapply.Ifyouqualify,askyourstateifithasaprogramthatmighthelpyoupay thepremiumsforanemployer-sponsoredplan.
IfyouoryourdependentsareeligibleforpremiumassistanceunderMedicaidorCHIP,aswellaseligibleunderyour employerplan,youremployermustallowyoutoenrollinyouremployerplanifyouaren’talreadyenrolled.Thisiscalleda “specialenrollment”opportunity,andyoumustrequestcoveragewithin60daysofbeingdeterminedeligiblefor premiumassistance.Ifyouhavequestionsaboutenrollinginyouremployerplan,contacttheDepartmentofLaborat www.askebsa.dol.govorcall1-866-444-EBSA(3272).
Ifyouliveinoneofthefollowingstates,youmaybeeligibleforassistancepayingyouremployerhealthplan premiums.ThefollowinglistofstatesiscurrentasofJuly31,2024.ContactyourStateformoreinformation oneligibility.
ALABAMA-Medicaid
Website:http://myalhipp.com/ Phone:1-855-692-5447
ARKANSAS–Medicaid
Website:http://myarhipp.com/ Phone:1-855-MyARHIPP(855-692-7447)
COLORADO–HealthFirstColorado(Colorado’sMedicaid Program)&ChildHealthPlanPlus(CHP+)
HealthFirstColoradoWebsite: https://www.healthfirstcolorado.com/ HealthFirstColoradoMemberContactCenter: 1-800-221-3943/StateRelay711
CHP+:https://hcpf.colorado.gov/child-health-plan-plus CHP+CustomerService:1-800-359-1991/StateRelay711 HealthInsuranceBuy-InProgram(HIBI): https://www.mycohibi.com/ HIBICustomerService:1-855-692-6442
ALASKA-Medicaid
TheAKHealthInsurancePremiumPaymentProgram
Website:http://myakhipp.com/ Phone:1-866-251-4861
Email:CustomerService@MyAKHIPP.com MedicaidEligibility:https://health.alaska.gov/dpa/Pages/default.aspx
CALIFORNIA–Medicaid
HealthInsurancePremiumPayment(HIPP)Program
Website:http://dhcs.ca.gov/hipp
Phone:916-445-8322
Fax:916-440-5676
Email:hipp@dhcs.ca.gov
FLORIDA–Medicaid
Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hi pp/index.html
Phone:1-877-357-3268
ComplianceNotices
GEORGIA–Medicaid
GAHIPPWebsite:https://medicaid.georgia.gov/health-insurancepremium-payment-program-hipp
Phone:678-564-1162,Press1
GACHIPRAWebsite:https://medicaid.georgia.gov/programs/thirdparty-liability/childrens-health-insurance-program-reauthorization-act2009-chipra
Phone:(678)564-1162,Press2
IOWA–MedicaidandCHIP(Hawki)
MedicaidWebsite:
IowaMedicaid|Health&HumanServices
MedicaidPhone:1-800-338-8366
HawkiWebsite:
Hawki-HealthyandWellKidsinIowa|Health&HumanServices
HawkiPhone:1-800-257-8563
HIPPWebsite:HealthInsurancePremiumPayment(HIPP)|Health& HumanServices(iowa.gov)
HIPPPhone:1-888-346-9562
KENTUCKY–Medicaid
KentuckyIntegratedHealthInsurancePremiumPaymentProgram(KIHIPP)Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx
Phone:1-855-459-6328
Email:KIHIPP.PROGRAM@ky.gov
KCHIPWebsite:https://kynect.ky.gov
Phone:1-877-524-4718
KentuckyMedicaidWebsite:https://chfs.ky.gov/agencies/dms
EnrollmentWebsite:
INDIANA–Medicaid
HealthInsurancePremiumPaymentProgram AllotherMedicaid
Website:https://www.in.gov/medicaid/ http://www.in.gov/fssa/dfr/ FamilyandSocialServicesAdministration Phone:1-800-403-0864
MemberServicesPhone:1-800-457-4584
KANSAS–Medicaid
Website:https://www.kancare.ks.gov/ Phone:1-800-792-4884
HIPPPhone:1-800-967-4660
LOUISIANA–Medicaid
Website:www.medicaid.la.govorwww.ldh.la.gov/lahipp Phone:1-888-342-6207(Medicaidhotline)or 1-855-618-5488(LaHIPP)
MASSACHUSETTS–MedicaidandCHIP MAINE–Medicaid
https://www.mymaineconnection.gov/benefits/s/?language=en_US Phone:1-800-442-6003;TTY:Mainerelay711
PrivateHealthInsurancePremiumWebpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone:1-800-977-6740;TTY:Mainerelay711
MINNESOTA–Medicaid
Website: https://mn.gov/dhs/health-care-coverage/ Phone:1-800-657-3672
MONTANA–Medicaid
Website:http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone:1-800-694-3084
Email:HHSHIPPProgram@mt.gov
NEVADA–Medicaid
MedicaidWebsite:http://dhcfp.nv.gov
MedicaidPhone:1-800-992-0900
Website:https://www.mass.gov/masshealth/pa Phone:1-800-862-4840
TTY:711
Email:masspremassistance@accenture.com
MISSOURI–Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone:573-751-2005
NEBRASKA–Medicaid
Website:http://www.ACCESSNebraska.ne.gov Phone:1-855-632-7633
Lincoln:402-473-7000 Omaha:402-595-1178
NEWHAMPSHIRE–Medicaid
Website:https://www.dhhs.nh.gov/programsservices/medicaid/health-insurance-premium-program Phone:603-271-5218
TollfreenumberfortheHIPPprogram:1-800-852-3345,ext. 15218
Email:DHHS.ThirdPartyLiabi@dhhs.nh.gov
ComplianceNotices
NEWJERSEY–MedicaidandCHIP
MedicaidWebsite:
http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/
Phone:1-800-356-1561
CHIPPremiumAssistancePhone:609-631-2392
CHIPWebsite:http://www.njfamilycare.org/index.html
CHIPPhone:1-800-701-0710(TTY:711)
NORTHCAROLINA–Medicaid
Website:https://medicaid.ncdhhs.gov/ Phone:919-855-4100
OKLAHOMA–MedicaidandCHIP
Website:http://www.insureoklahoma.org
Phone:1-888-365-3742
NEWYORK–Medicaid
Website:https://www.health.ny.gov/health_care/medicaid/ Phone:1-800-541-2831
NORTHDAKOTA–Medicaid
Website:https://www.hhs.nd.gov/healthcare Phone:1-844-854-4825
OREGON–MedicaidandCHIP
Website:http://healthcare.oregon.gov/Pages/index.aspx Phone:1-800-699-9075
RHODEISLAND–MedicaidandCHIP PENNSYLVANIA–MedicaidandCHIP
Website:https://www.pa.gov/en/services/dhs/apply-for-medicaidhealth-insurance-premium-payment-program-hipp.html
Phone:1-800-692-7462
CHIPWebsite:Children'sHealthInsuranceProgram(CHIP)(pa.gov)
Website:http://www.eohhs.ri.gov/ Phone:1-855-697-4347,or 401-462-0311(DirectRIteShareLine)
CHIPPhone:1-800-986-KIDS(5437) SOUTHDAKOTA-Medicaid
Website:https://www.scdhhs.gov
Phone:1-888-549-0820
Website:HealthInsurancePremiumPayment(HIPP)Program| TexasHealthandHumanServices
Phone:1-800-440-0493
Website:HealthInsurancePremiumPayment(HIPP)Program| DepartmentofVermontHealthAccess Phone:1-800-250-8427
Website:http://dss.sd.gov Phone:1-888-828-0059
Utah’sPremiumPartnershipforHealthInsurance(UPP)Website: https://medicaid.utah.gov/upp/ Email:upp@utah.govPhone:1-888-222-2542 AdultExpansionWebsite:https://medicaid.utah.gov/expansion/ UtahMedicaidBuyoutProgramWebsite: https://medicaid.utah.gov/buyout-program/ CHIPWebsite:https://chip.utah.gov/
Website:https://coverva.dmas.virginia.gov/learn/premiumassistance/famis-select https://coverva.dmas.virginia.gov/learn/premiumassistance/health-insurance-premium-payment-hipp-programs Medicaid/CHIPPhone:1-800-432-5924
Website:https://www.hca.wa.gov/ Phone:1-800-562-3022
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone:1-800-362-3002
Website:https://dhhr.wv.gov/bms/ http://mywvhipp.com/ MedicaidPhone:304-558-1700
CHIPToll-freephone:1-855-MyWVHIPP(1-855-699-8447)
WYOMING–Medicaid
Website:https://health.wyo.gov/healthcarefin/medicaid/programsand-eligibility/ Phone:1-800-251-1269
ToseeifanyotherstateshaveaddedapremiumassistanceprogramsinceJuly31,2024,orformoreinformationon specialenrollmentrights,contacteither:
U.S.DepartmentofLabor EmployeeBenefitsSecurityAdministration www.dol.gov/agencies/ebsa 1-866-444-EBSA(3272)
U.S.DepartmentofHealthandHumanServices CentersforMedicare&MedicaidServices www.cms.hhs.gov 1-877-267-2323,MenuOption4,Ext.61565
ComplianceNotices
YourRightsandProtectionsAgainstSurpriseMedicalBills
Whenyougetemergencycareoraretreatedbyanout-of-networkprovideratanin-networkhospitalorambulatorysurgical center,youareprotectedfrombalancebilling.Inthesecases,youshouldn’tbechargedmorethanyourplan’scopayments, coinsuranceand/ordeductible.
Whatis“balancebilling”(sometimescalled“surprisebilling”)?
Whenyouseeadoctororotherhealthcareprovider,youmayowecertainout-of-pocket-costs,likeasuchasacopayment, coinsurance,ordeductible.Youmayhaveadditionalcostsorhavetopaytheentirebillifyouseeaproviderorvisitahealth carefacilitythatisn’tinyourhealthplan’snetwork.
“Out-of-network”meansprovidersandfacilitiesthathaven’tsignedacontractwithyourhealthplantoprovideservices.Outof-networkprovidersmaybepermittedtobillyouforthedifferencebetweenwhatyourplanpaysandthefullamount chargedforaservice.Thisiscalled“balancebilling.”Thisamountislikelymorethanin-networkcostsforthesameservice andmightnotcounttowardyourplan’sdeductibleorannualout-of-pocketlimit.
“Surprisebilling”isanunexpectedbalancebill.Thiscanhappenwhenyoucan’tcontrolwhoisinvolvedinyourcare—like whenyouhaveanemergencyorwhenyouscheduleavisitatanin-networkfacilitybutareunexpectedlytreatedbyanoutof-networkprovider.Surprisemedicalbillscouldcostthousandsofdollarsdependingontheprocedureorservice.
Youareprotectedfrombalancebillingfor: Emergencyservices
Ifyouhaveanemergencymedicalconditionandgetemergencyservicesfromanout-of-networkproviderorfacility,the mosttheycanbillyouisyourplan’sin-networkcost-sharingamount(suchascopayments,coinsurance,anddeductibles). Youcan’tbebalancebilledfortheseemergencyservices.Thisincludesservicesyoumaygetafteryou’reinstable condition,unlessyougivewrittenconsentandgiveupyourprotectionsnottobebalancedbilledforthesepost-stabilization services.
Certainservicesatanin-networkhospitalorambulatorysurgicalcenter
Whenyougetservicesfromanin-networkhospitalorambulatorysurgicalcenter,certainproviderstheremaybeout-ofnetwork.Inthesecases,themostthoseproviderscanbillyouisyourplan’sin-networkcost-sharingamount.Thisappliesto emergencymedicine,anesthesia,pathology,radiology,laboratory,neonatology,assistantsurgeon,hospitalist,orintensivist services.Theseproviderscan’tbalancebillyouandmaynotaskyoutogiveupyourprotectionsnottobebalancebilled.
Ifyougetothertypesofservicesatthesein-networkfacilities,out-of-networkproviderscan’tbalancebillyou,unlessyou givewrittenconsentandgiveupyourprotections.
You’reneverrequiredtogiveupyourprotectionsfrombalancebilling.Youalsoaren’trequiredtogetout-ofnetworkcare.Youcanchooseaproviderorfacilityinyourplan’snetwork.
Whenbalancebillingisn’tallowed,youalsohavethefollowingprotections:
•You’reonlyresponsibleforpayingyourshareofthecost(likethecopayments,coinsurance,anddeductiblethatyouwould payiftheproviderorfacilitywasin-network).Yourhealthplanwillpayanyadditionalcoststoout-of-networkprovidersand facilitiesdirectly.
•Generally,yourhealthplanmust:
oCoveremergencyserviceswithoutrequiringyoutogetapprovalforservicesinadvance(alsoknownas“prior authorization”).
oCoveremergencyservicesbyout-of-networkproviders.
oBasewhatyouowetheproviderorfacility(cost-sharing)onwhatitwouldpayanin-networkproviderorfacilityand showthatamountinyourexplanationofbenefits.
oCountanyamountyoupayforemergencyservicesorout-of-networkservicestowardyourin-networkdeductibleand out-of-pocketlimit.
Ifyoubelieveyou’vebeenwronglybilled,contactthefederalNoSurprisesHelpDeskat1-800-985-3059.Visit www.cms.gov/nosurprises/consumersformoreinformationaboutyourrightsunderfederallaw.
ComplianceNotices
FamilyandMedicalLeaveAct(FMLA)
LeaveEntitlements.Eligibleemployeeswhoworkforacoveredemployercantakeupto12weeksofunpaid,job-protected leaveina12-monthperiodforthefollowingreasons:
•Thebirthofachildorplacementofachildforadoptionorfostercare;
•Tobondwithachild(leavemustbetakenwithinoneyearofthechild’sbirthorplacement);
•Tocarefortheemployee’sspouse,child,orparentwhohasaqualifyingserioushealthcondition;
•Fortheemployee’sownqualifyingserioushealthconditionthatmakestheemployeeunabletoperformtheemployee’s job;
•Forqualifyingexigenciesrelatedtotheforeigndeploymentofamilitarymemberwhoistheemployee’sspouse,child,or parent.
Aneligibleemployeewhoisacoveredservicemember’sspouse,child,parent,ornextofkinmayalsotakeupto26weeks ofFMLAleaveinasingle12-monthperiodtocarefortheservicememberwithaseriousinjuryorillness.Anemployeedoes notneedtouseleaveinoneblock.Whenitismedicallynecessaryorotherwisepermitted,employeesmaytakeleave intermittentlyoronareducedschedule.
Employeesmaychoose,oranemployermayrequire,useofaccruedpaidleavewhiletakingFMLAleave.Ifanemployee substitutesaccruedpaidleaveforFMLAleave,theemployeemustcomplywiththeemployer’snormalpaidleavepolicies.
BenefitsandProtections.WhileemployeesareonFMLAleave,employersmustcontinuehealthinsurancecoverageasif theemployeeswerenotonleave.UponreturnfromFMLAleave,mostemployeesmustberestoredtothesamejoborone nearlyidenticaltoitwithequivalentpay,benefits,andotheremploymenttermsandconditions.Anemployermaynot interferewithanindividual’sFMLArightsorretaliateagainstsomeoneforusingortryingtouseFMLAleave,opposingany practicemadeunlawfulbytheFMLA,orbeinginvolvedinanyproceedingunderorrelatedtotheFMLA.
EligibilityRequirements.Anemployeewhoworksforacoveredemployermustmeetthreecriteriainordertobeeligiblefor FMLAleave.Theemployeemust:
•Haveworkedfortheemployerforatleast12months;
•Haveatleast1,250hoursofserviceinthe12monthsbeforetakingleave;*and
•Workatalocationwheretheemployerhasatleast50employeeswithin75milesoftheemployee’sworksite.*Special “hoursofservice”requirementsapplytoairlineflightcrewemployees.
RequestingLeave.Generally,employeesmustgive30-days’advancenoticeoftheneedforFMLAleave.Ifitisnotpossible togive30-days’notice,anemployeemustnotifytheemployerassoonaspossibleand,generally,followtheemployer’s usualprocedures.Employeesdonothavetoshareamedicaldiagnosisbutmustprovideenoughinformationtothe employersoitcandetermineiftheleavequalifiesforFMLAprotection.Sufficientinformationcouldincludeinformingan employerthattheemployeeisorwillbeunabletoperformhisorherjobfunctions,thatafamilymembercannotperform dailyactivities,orthathospitalizationorcontinuingmedicaltreatmentisnecessary.Employeesmustinformtheemployerif theneedforleaveisforareasonforwhichFMLAleavewaspreviouslytakenorcertified.Employerscanrequirea certificationorperiodicrecertificationsupportingtheneedforleave.Iftheemployerdeterminesthatthecertificationis incomplete,itmustprovideawrittennoticeindicatingwhatadditionalinformationisrequired.
EmployerResponsibilities.Onceanemployerbecomesawarethatanemployee’sneedforleaveisforareasonthatmay qualifyundertheFMLA,theemployermustnotifytheemployeeifheorsheiseligibleforFMLAleaveand,ifeligible,must alsoprovideanoticeofrightsandresponsibilitiesundertheFMLA.Iftheemployeeisnoteligible,theemployermust provideareasonforineligibility.EmployersmustnotifyitsemployeesifleavewillbedesignatedasFMLAleave,andifso, howmuchleavewillbedesignatedasFMLAleave.
Enforcement.EmployeesmayfileacomplaintwiththeU.S.DepartmentofLabor,WageandHourDivision,ormaybringa privatelawsuitagainstanemployer.TheFMLAdoesnotaffectanyfederalorstatelawprohibitingdiscriminationor supersedeanystateorlocallaworcollectivebargainingagreementthatprovidesgreaterfamilyormedicalleaverights.
ComplianceNotices
Pleasereadthisnoticecarefullyandkeepitwhereyoucanfindit.Thisnoticehasinformationaboutyourcurrent prescriptiondrugcoveragewithTheEticaGroup,Inc.GroupHealthPlanandaboutyouroptionsunder Medicare’sprescriptiondrugcoverage.Thisinformationcanhelpyoudecidewhetherornotyouwanttojoina Medicaredrugplan.Ifyouareconsideringjoining,youshouldcompareyourcurrentcoverage,includingwhich drugsarecoveredatwhatcost,withthecoverageandcostsoftheplansofferingMedicareprescriptiondrug coverageinyourarea.Informationaboutwhereyoucangethelptomakedecisionsaboutyourprescriptiondrug coverageisattheendofthisnotice.
TherearetwoimportantthingsyouneedtoknowaboutyourcurrentcoverageandMedicare’sprescriptiondrug coverage:
1.Medicareprescriptiondrugcoveragebecameavailablein2006toeveryonewithMedicare.Youcangetthis coverageifyoujoinaMedicarePrescriptionDrugPlanorjoinaMedicareAdvantagePlan(likeanHMOor PPO)thatoffersprescriptiondrugcoverage.AllMedicaredrugplansprovideatleastastandardlevelof coveragesetbyMedicare.Someplansmayalsooffermorecoverageforahighermonthlypremium.
2.TheEticaGroup,Inc.hasdeterminedthattheprescriptiondrugcoverageofferedbytheTheEticaGroup, Inc.GroupHealthPlanis,onaverageforallplanparticipants,expectedtopayoutasmuchasstandard MedicareprescriptiondrugcoveragepaysandisthereforeconsideredCreditableCoverage.Becauseyour existingcoverageisCreditableCoverage,youcankeepthiscoverageandnotpayahigherpremium(a penalty)ifyoulaterdecidetojoinaMedicaredrugplan.
WhenCanYouJoinAMedicareDrugPlan?
YoucanjoinaMedicaredrugplanwhenyoufirstbecomeeligibleforMedicareandeachyearfromOctober15th toDecember7th
However,ifyouloseyourcurrentcreditableprescriptiondrugcoverage,throughnofaultofyourown,youwill alsobeeligibleforatwo(2)monthSpecialEnrollmentPeriod(SEP)tojoinaMedicaredrugplan.
WhatHappensToYourCurrentCoverageIfYouDecidetoJoinAMedicareDrugPlan?
IfyoudecidetojoinaMedicaredrugplan,yourcurrentTheEticaGroup,Inc.GroupHealthPlancoveragewill notbeaffected.IfyoukeepyourcurrentcoverageandelectMedicarePartD,yourTheEticaGroup,Inc.Group HealthPlancoveragemaycoordinatewithyourMedicarePartDcoverage.IfyoudodecidetojoinaMedicare drugplananddropyourcurrentTheEticaGroup,Inc.GroupHealthPlancoverage,beawarethatyouandyour dependentswillnotbeabletogetthiscoverageback,unlessyouhaveaqualifyinglifeeventoruntilthenext openenrollment.
WhenWillYouPayAHigherPremium(Penalty)ToJoinAMedicareDrugPlan?
YoushouldalsoknowthatifyoudroporloseyourcurrentcoveragewithTheEticaGroup,Inc.anddon’tjoina Medicaredrugplanwithin63continuousdaysafteryourcurrentcoverageends,youmaypayahigherpremium (apenalty)tojoinaMedicaredrugplanlater.
Ifyougo63continuousdaysorlongerwithoutcreditableprescriptiondrugcoverage,yourmonthlypremiummay goupbyatleast1%oftheMedicarebasebeneficiarypremiumpermonthforeverymonththatyoudidnothave
12 ComplianceNotices
thatcoverage.Forexample,ifyougonineteenmonthswithoutcreditablecoverage,yourpremiummay consistentlybeatleast19%higherthantheMedicarebasebeneficiarypremium.Youmayhavetopaythis higherpremium(apenalty)aslongasyouhaveMedicareprescriptiondrugcoverage.Inaddition,youmayhave towaituntilthefollowingOctobertojoin.
ForMoreInformationAboutThisNoticeOrYourCurrentPrescriptionDrugCoverage
Contactthepersonlistedbelowforfurtherinformation.
NOTE:You’llgetthisnoticeeachyear.YouwillalsogetitbeforethenextperiodyoucanjoinaMedicaredrug plan,andifthiscoveragethroughTheEticaGroup,Inc.changes.Youalsomayrequestacopyofthisnoticeat anytime.
ForMoreInformationAboutYourOptionsUnderMedicarePrescriptionDrugCoverage
MoredetailedinformationaboutMedicareplansthatofferprescriptiondrugcoverageisinthe“Medicare&You” handbook.You’llgetacopyofthehandbookinthemaileveryyearfromMedicare.Youmayalsobecontacted directlybyMedicaredrugplans.
FormoreinformationaboutMedicareprescriptiondrugcoverage:
•Visitwww.medicare.gov
•CallyourStateHealthInsuranceAssistanceProgram(seetheinsidebackcoverofyourcopyofthe “Medicare&You”handbookfortheirtelephonenumber)forpersonalizedhelp
•Call1-800-MEDICARE(1-800-633-4227).TTYusersshouldcall1-877-486-2048.
Ifyouhavelimitedincomeandresources,extrahelppayingforMedicareprescriptiondrugcoverageis available.Forinformationaboutthisextrahelp,visitSocialSecurityonthewebatwww.socialsecurity.gov,or callthemat1-800-772-1213(TTY1-800-325-0778).
Remember:KeepthisCreditableCoveragenotice.IfyoudecidetojoinoneoftheMedicaredrug plans,youmayberequiredtoprovideacopyofthisnoticewhenyoujointoshowwhetherornot youhavemaintainedcreditablecoverageand,therefore,whetherornotyouarerequiredtopaya higherpremium(apenalty).
EffectiveDate:01/01/2025
NameofEntity/Sender:TheEticaGroup,Inc.
Contact--Position/Office:KirstenHarwood–HumanResources
Address:8720CastleCreekParkwayE.Dr,Suite400,Indianapolis,IN46250
PhoneNumber:317-466-9520
Pleaserefertotheofficialplandocumentsformorecompletedescriptionsofthebenefitplans.Intheeventofanyinconsistenciesordiscrepancies betweentheinformationprovidedinthisguideandtheofficialplandocuments,theofficialplandocumentswillprevail.TheEticaGroupreservesthe righttoamend,suspendorterminateanybenefitplan,inwholeorinpart,atanytimewithoutnotice,includingmakingchangestocomplywithand exerciseitsoptionsunderapplicablelaws.TheauthoritytomakesuchchangesrestswiththePlanAdministrator.Toviewthesummaryplan descriptionsandcertificatesofcoverage,visitwww.myuhc.com.YoumaycontactHumanResourcesat317-466-9520torequestaprintedcopyof thesummaryplandescriptionandotherofficialplanorprogramdocuments,whichwillbeprovidedatnocosttoyou.
