Plan Notices

Patient Protection Plan Notice (Non-Grandfathered)

Our HMO group health plan requires the designation of a primary care provider. You have the right to designate any
primary care provider who participates in our network and who is available to accept you or your family members as
patients. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization
from your group health plan or any other person (including a primary care provider) in order to obtain access to obstetrical
or gynecological care from a healthcare professional in our network who specializes in obstetrics or gynecology. The
healthcare professional, however, may be required to comply with certain procedures (including obtaining prior
authorization for certain services) following a pre-approved treatment plan or procedures for making referrals. For
information about how to select a primary care provider or for a list of participating primary care providers, contact your
plan administrator.
Patient Protection Plan Notice (Grandfathered)
This group health plan is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable
Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain aspects of basic
health coverage that were already in effect when the law was enacted. Having a grandfathered health plan means that
your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans (e.g., the
requirement for the provision of preventive health services without any cost sharing). However, grandfathered health
plans must comply with certain other consumer protections in the Affordable Care Act (e.g., the elimination of lifetime
limits on benefits).
Questions regarding which protections do and do not apply to a grandfathered health plan and what might cause a plan to
shift from grandfathered health plan status can be directed to the plan administrator. You may also contact the Employee
Benefits Security Administration at the U.S. Department of Labor at 866.444.3272 or www.dol.gov/ebsa/healthreform This
website features a table summarizing which protections do and do not apply to grandfathered health plans.
Newborns and Mothers Health Protection Act of 1996 (NMHPA)
Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital
length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal
delivery or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mothers
or newborns attending provider from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as
applicable) after consulting with the mother. In any case, plans and issuers may not, under federal law, require that a
provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay of 48 hours or less (or
96 hours or less).
Special Enrollment Notice
If you are declining enrollment 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 the 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). 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.
However, you must request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. To
request special enrollment or obtain more information, contact your plan administrator.

Womens Health and Cancer Rights Act of 1998 (WHCRA) Enrollment Notice
If you have had or are planning to have a mastectomy, you may be entitled to certain benefits under the 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 the following:
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 subject to the same deductibles and co-insurance applicable to other medical and surgical benefits
provided under this plan. If you would like more information on WHCRA benefits, call your plan administrator.
Premium Assistance Under Medicaid and CHIP
Medicaid and the childrens health insurance program (CHIP) offer free or low-cost health coverage to children and
families. If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage. These states use funds from
their Medicaid or CHIP programs to help people who are eligible for these programs but also have access to health
insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for
these premium assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP, you can 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, you can contact your state Medicaid or CHIP office. Dial 877.KIDS.NOW
(543.7669) or visit www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the state if it has a program
that might help you pay the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as
under your employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled.
This is considered 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, you can contact the
Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 866.444.EBSA (3272).

California Medicaid
Website: www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx

email: hipp@dhcs.ca.gov

Fax: 916.440.5676
All Other States

To see if other states have premium assistance programs 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

866.444.EBSA (3272)

877.267.2323, ext. 61565

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