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New Health Insurance Marketplace Coverage Options and Your Health CoveragePART A: General Information ΈΙΖΟΜΖΪΡΒΣΥΤΠΗΥΙΖΙΖΒΝΥΙΔΒΣΖΝΒΨΥΒΜΖΖΗΗΖΔΥΚΟΥΙΖΣΖΨΚΝΝΓΖΒΟΖΨΨΒΪΥΠΓΦΪΙΖΒΝΥΙΚΟΤΦΣΒΟΔΖ:ΥΙΖΖΒΝΥΙͺΟΤΦΣΒΟΔΖ;ΒΣΜΖΥΡΝΒΔΖ΅ΠΒΤΤΚΤΥΪΠΦΒΤΪΠΦΖΧΒΝΦΒΥΖΠΡΥΚΠΟΤΗΠΣΪΠΦΒΟΕΪΠΦΣΗΒΞΚΝΪΥΙΚΤΟΠΥΚΔΖΡΣΠΧΚΕΖΤΤΠΞΖΓΒΤΚΔΚΟΗΠΣΞΒΥΚΠΟΒΓΠΦΥΥΙΖΟΖΨ;ΒΣΜΖΥΡΝΒΔΖΒΟΕΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕΙΖΒΝΥΙΔΠΧΖΣΒΘΖΠΗΗΖΣΖΕΓΪΪΠΦΣΖΞΡΝΠΪΖΣWhat is the Health Insurance Marketplace? ΅ΙΖ;ΒΣΜΖΥΡΝΒΔΖΚΤΕΖΤΚΘΟΖΕΥΠΙΖΝΡΪΠΦΗΚΟΕΙΖΒΝΥΙΚΟΤΦΣΒΟΔΖΥΙΒΥΞΖΖΥΤΪΠΦΣΟΖΖΕΤΒΟΕΗΚΥΤΪΠΦΣΓΦΕΘΖΥ΅ΙΖ;ΒΣΜΖΥΡΝΒΔΖΠΗΗΖΣΤΠΟΖΤΥΠΡΤΙΠΡΡΚΟΘΥΠΗΚΟΕΒΟΕΔΠΞΡΒΣΖΡΣΚΧΒΥΖΙΖΒΝΥΙΚΟΤΦΣΒΟΔΖΠΡΥΚΠΟΤΊΠΦΞΒΪΒΝΤΠΓΖΖΝΚΘΚΓΝΖΗΠΣΒΟΖΨΜΚΟΕΠΗΥΒΩΔΣΖΕΚΥΥΙΒΥΝΠΨΖΣΤΪΠΦΣΞΠΟΥΙΝΪΡΣΖΞΚΦΞΣΚΘΙΥΒΨΒΪΡΖΟΖΟΣΠΝΝΞΖΟΥΗΠΣΙΖΒΝΥΙΚΟΤΦΣΒΟΔΖΔΠΧΖΣΒΘΖΥΙΣΠΦΘΙΥΙΖ;ΒΣΜΖΥΡΝΒΔΖΓΖΘΚΟΤΚΟΔΥΠΓΖΣΗΠΣΔΠΧΖΣΒΘΖΤΥΒΣΥΚΟΘΒΤΖΒΣΝΪΒΤͻΒΟΦΒΣΪCan I Save Money on my Health Insurance Premiums in the Marketplace? ΊΠΦΞΒΪΦΒΝΚΗΪΥΠΤΒΧΖΞΠΟΖΪΒΟΕΝΠΨΖΣΪΠΦΣΞΠΟΥΙΝΪΡΣΖΞΚΦΞΓΦΥΠΟΝΪΚΗΪΠΦΣΖΞΡΝΠΪΖΣΕΠΖΤΟΠΥΠΗΗΖΣΔΠΧΖΣΒΘΖΠΣΠΗΗΖΣΤΔΠΧΖΣΒΘΖΥΙΒΥΕΠΖΤΟΥΞΖΖΥΔΖΣΥΒΚΟΤΥΒΟΕΒΣΕΤ΅ΙΖΤΒΧΚΟΘΤΠΟΪΠΦΣΡΣΖΞΚΦΞΥΙΒΥΪΠΦΣΖΖΝΚΘΚΓΝΖΗΠΣΕΖΡΖΟΕΤΠΟΪΠΦΣΙΠΦΤΖΙΠΝΕΚΟΔΠΞΖDoes Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? ΊΖΤͺΗΪΠΦΙΒΧΖΒΟΠΗΗΖΣΠΗΙΖΒΝΥΙΔΠΧΖΣΒΘΖΗΣΠΞΪΠΦΣΖΞΡΝΠΪΖΣΥΙΒΥΞΖΖΥΤΔΖΣΥΒΚΟΤΥΒΟΕΒΣΕΤΪΠΦΨΚΝΝΟΠΥΓΖΖΝΚΘΚΓΝΖΗΠΣΒΥΒΩΔΣΖΕΚΥΥΙΣΠΦΘΙΥΙΖ;ΒΣΜΖΥΡΝΒΔΖΒΟΕΞΒΪΨΚΤΙΥΠΖΟΣΠΝΝΚΟΪΠΦΣΖΞΡΝΠΪΖΣΤΙΖΒΝΥΙΡΝΒΟΠΨΖΧΖΣΪΠΦΞΒΪΓΖΖΝΚΘΚΓΝΖΗΠΣΒΥΒΩΔΣΖΕΚΥΥΙΒΥΝΠΨΖΣΤΪΠΦΣΞΠΟΥΙΝΪΡΣΖΞΚΦΞΠΣΒΣΖΕΦΔΥΚΠΟΚΟΔΖΣΥΒΚΟΔΠΤΥΤΙΒΣΚΟΘΚΗΪΠΦΣΖΞΡΝΠΪΖΣΕΠΖΤΟΠΥΠΗΗΖΣΔΠΧΖΣΒΘΖΥΠΪΠΦΒΥΒΝΝΠΣΕΠΖΤΟΠΥΠΗΗΖΣΔΠΧΖΣΒΘΖΥΙΒΥΞΖΖΥΤΔΖΣΥΒΚΟΤΥΒΟΕΒΣΕΤͺΗΥΙΖΔΠΤΥΠΗΒΡΝΒΟΗΣΠΞΪΠΦΣΖΞΡΝΠΪΖΣΥΙΒΥΨΠΦΝΕΔΠΧΖΣΪΠΦΒΟΕΟΠΥΒΟΪΠΥΙΖΣΞΖΞΓΖΣΤΠΗΪΠΦΣΗΒΞΚΝΪΚΤΞΠΣΖΥΙΒΟΠΗΪΠΦΣΙΠΦΤΖΙΠΝΕΚΟΔΠΞΖΗΠΣΥΙΖΪΖΒΣΠΣΚΗΥΙΖΔΠΧΖΣΒΘΖΪΠΦΣΖΞΡΝΠΪΖΣΡΣΠΧΚΕΖΤΕΠΖΤΟΠΥΞΖΖΥΥΙΖΞΚΟΚΞΦΞΧΒΝΦΖΤΥΒΟΕΒΣΕΤΖΥΓΪΥΙΖͲΗΗΠΣΕΒΓΝΖʹΒΣΖͲΔΥΪΠΦΞΒΪΓΖΖΝΚΘΚΓΝΖΗΠΣΒΥΒΩΔΣΖΕΚΥͿΠΥΖͺΗΪΠΦΡΦΣΔΙΒΤΖΒΙΖΒΝΥΙΡΝΒΟΥΙΣΠΦΘΙΥΙΖ;ΒΣΜΖΥΡΝΒΔΖΚΟΤΥΖΒΕΠΗΒΔΔΖΡΥΚΟΘΙΖΒΝΥΙΔΠΧΖΣΒΘΖΠΗΗΖΣΖΕΓΪΪΠΦΣΖΞΡΝΠΪΖΣΥΙΖΟΪΠΦΞΒΪΝΠΤΖΥΙΖΖΞΡΝΠΪΖΣΔΠΟΥΣΚΓΦΥΚΠΟΚΗΒΟΪΥΠΥΙΖΖΞΡΝΠΪΖΣΠΗΗΖΣΖΕΔΠΧΖΣΒΘΖͲΝΤΠΥΙΚΤΖΞΡΝΠΪΖΣΔΠΟΥΣΚΓΦΥΚΠΟΒΤΨΖΝΝΒΤΪΠΦΣΖΞΡΝΠΪΖΖΔΠΟΥΣΚΓΦΥΚΠΟΥΠΖΞΡΝΠΪΖΣΠΗΗΖΣΖΕΔΠΧΖΣΒΘΖΚΤΠΗΥΖΟΖΩΔΝΦΕΖΕΗΣΠΞΚΟΔΠΞΖΗΠΣͷΖΕΖΣΒΝΒΟΕ΄ΥΒΥΖΚΟΔΠΞΖΥΒΩΡΦΣΡΠΤΖΤΊΠΦΣΡΒΪΞΖΟΥΤΗΠΣΔΠΧΖΣΒΘΖΥΙΣΠΦΘΙΥΙΖ;ΒΣΜΖΥΡΝΒΔΖΒΣΖΞΒΕΖΠΟΒΟΒΗΥΖΣΥΒΩΓΒΤΚΤHow Can I Get More Information? ͷΠΣΞΠΣΖΚΟΗΠΣΞΒΥΚΠΟΒΓΠΦΥΪΠΦΣΔΠΧΖΣΒΘΖΠΗΗΖΣΖΕΓΪΪΠΦΣΖΞΡΝΠΪΖΣΡΝΖΒΤΖΔΙΖΔΜΪΠΦΣΤΦΞΞΒΣΪΡΝΒΟΕΖΤΔΣΚΡΥΚΠΟΠΣΔΠΟΥΒΔΥ΅ΙΖ;ΒΣΜΖΥΡΝΒΔΖΔΒΟΙΖΝΡΪΠΦΖΧΒΝΦΒΥΖΪΠΦΣΔΠΧΖΣΒΘΖΠΡΥΚΠΟΤΚΟΔΝΦΕΚΟΘΪΠΦΣΖΝΚΘΚΓΚΝΚΥΪΗΠΣΔΠΧΖΣΒΘΖΥΙΣΠΦΘΙΥΙΖ;ΒΣΜΖΥΡΝΒΔΖΒΟΕΚΥΤΔΠΤΥΝΖΒΤΖΧΚΤΚΥΖΒΝΥΙʹΒΣΖΘΠΧΗΠΣΞΠΣΖΚΟΗΠΣΞΒΥΚΠΟΚΟΔΝΦΕΚΟΘΒΟΠΟΝΚΟΖΒΡΡΝΚΔΒΥΚΠΟΗΠΣΙΖΒΝΥΙΚΟΤΦΣΒΟΔΖΔΠΧΖΣΒΘΖΒΟΕΔΠΟΥΒΔΥΚΟΗΠΣΞΒΥΚΠΟΗΠΣΒΖΒΝΥΙͺΟΤΦΣΒΟΔΖ;ΒΣΜΖΥΡΝΒΔΖΚΟΪΠΦΣΒΣΖΒͲΟΖΞΡΝΠΪΖΣΤΡΠΟΤΠΣΖΕΙΖΒΝΥΙΡΝΒΟΞΖΖΥΤΥΙΖΞΚΟΚΞΦΞΧΒΝΦΖΤΥΒΟΕΒΣΕΚΗ ΥΙΖΡΝΒΟΤΤΙΒΣΖΠΗΥΙΖΥΠΥΒΝΒΝΝΠΨΖΕΓΖΟΖΗΚΥΔΠΤΥΤΔΠΧΖΣΖΕΓΪΥΙΖΡΝΒΟΚΤ ΟΠ ΝΖΤΤΥΙΒΟΡΖΣΔΖΟΥΠΗΤΦΔΙΔΠΤΥΤForm Approved OMB No. 1210-0149 H[SLUHV5312020 Lela Medina
PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name 4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to: All employees. Eligible employees are: Some employees. Eligible employees are: With respect to dependents: We do offer coverage. Eligible dependents are: We do not offer coverage. If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. ** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums. The information in this Employee Benefits Communicator is presented for illustrative purposes only. The text contained in this Guide was taken from various summary plan descriptions and benefit information documents. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefit Enrollment Guide and the actual plan documents, the actual plan documents will prevail. If you have any questions about this summary, contact Human Resources. 13 x Full-time employee working 30 hours or more per week once they have satisfied their waiting period x Spouse Children to the age 26 x NTS Amega West USA Inc85-288835718601 Intercontinental Crossing Dr HoustonTX77073Lela Medinalmedina@ntsamega-west.com
OMB 0938-0990 CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Important Notice from Your Employer 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 your employer 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. Your employer has determined that the prescription drug coverage offered by the (Insert Name of 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.
OMB 0938-0990 CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 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 employer’s coverage will not be affected. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current employer’s coverage, be aware that you and your dependents will not be able to get this coverage back. 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 your employer 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 your employer 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:
OMB 0938-0990 CMS Form 10182-CC Updated April 1, 2011 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. 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 (1-800-633-4227). TTY users should call 1-877-486-2048. 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 1-800-772-1213 (TTY 1-800-325-0778). 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).
ANNUAL NOTICESYou have certain rights and responsibilities as an employee with access tobenefits. This information is somewhat general and may not include all noticesand content you may be entitled to receive. Your employer, plan sponsor, orcarrier may provide additional information.Health Insurance Marketplace Options and Your Health CoverageThe Health Insurance Marketplace is designed to help individuals find, compare, and purchase privateindividual health insurance. The Marketplace does not affect your eligibility for coverage or youremployer's group health plan.Individuals may be eligible for a tax credit that lowers the monthly premium of coverage purchased inthe Marketplace. However, if you are eligible for an employer's group health plan, you may not beeligible for a tax credit through the Marketplace if the employer group health plan meets the"minimum value" and "affordability" standards set by the Affordable Care Act. Additionally, if youpurchase your own health plan through the Marketplace instead of accepting health coverage offeredby your employer, then you will lose the employer contribution towards coverage. This employercontribution - as well as your employee contribution towards coverage - is often excluded fromincome for Federal and State income tax purposes. Your payments for coverage you purchase throughthe Marketplace are made on an after-tax basis.Open enrollment for Individual health insurance coverage through the Marketplace occurs at the endof each calendar year for coverage effective the following January 1st. If you are interested, pleasevisit HealthCare.gov for more information, including an online application for health insurancecoverage and contact information for a Health Insurance Marketplace in your area.
Notice of Special Enrollment RightsIf you are declining enrollment for yourself or your dependents (including your spouse) because ofother health insurance or group health plan coverage, you may be able to enroll yourself and yourdependents in this plan if you or your dependents lose eligibility for that other coverage (or if theemployer stops contributing toward your or your dependents’ other coverage). However, you mustrequest enrollment within 30 days or after your or your dependents’ other coverage ends (or afterthe employer stops contributing toward the other coverage).In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement foradoption, you may be able to enroll yourself and your dependents. However, you must requestenrollment within 30 days after the marriage, birth, adoption, or placement for adoption.To request special enrollment or obtain more information, contact Human Resources.Women's Health & Cancer Rights Act (WHCRA)The Women’s Health and Cancer Rights Act requires group health plans that provide coveragefor mastectomies to also cover reconstructive surgery and prostheses following mastectomies. The law mandates that a member receiving benefits for a medically necessary mastectomy whoelects breast reconstruction after the mastectomy will receive coverage for: • reconstruction of the breast on which mastectomy has been performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance; • prostheses; and • treatment of physical complications of all stages of mastectomy, including lymphedemas. This coverage will be provided in a manner determined in consultation with the attendingphysician and the patient, and it will be subject to the same annual deductibles and coinsurance provisions as those establishedfor other benefits under the plan. Please call your medical plan using the number on your identification card or contactthe employer for more information.
Availability of Notice of Privacy Practices The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires health plans toprotect the confidentiality of your personal health information (“PHI”). HIPAA also requires thathealth plans maintain privacy notices which provide a complete description of your rights underHIPAA’s privacy rules. For insured coverage, the health insurance plan privacy notices aremaintained by the insurance providers. For self-insured coverage, the privacy notice is maintainedby your employer. In general, the plans will not use or further disclose PHI except as necessary fortreatment, payment, health plan operations and plan administration or as permitted or required bylaw. Under HIPAA, you have certain rights with respect to your protected health information andthe right to file a complaint with the plan or the Secretary of the U.S. Department of Health andHuman Services if you believe your rights under HIPAA has been violated. Premium Assistance Under Medicaid and the Children’s HealthInsurance Program (CHIP) f you or your children are eligible for Medicaid or CHIP and you’re eligible for health coveragefrom your employer, your state may have a premium assistance program that can help pay forcoverage, using funds from their Medicaid or CHIP programs. If you or your children aren’teligible 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 HealthInsurance 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 listedon the DOL website https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/chipra/model-notice.pdf,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 orany of your dependents might be eligible for either of these programs, contact your StateMedicaid or CHIP office or dial 1-877-KIDS NOW or https://www.insurekidsnow.gov/ to find outhow to apply. If you qualify, ask your state if it has a program that might help you pay thepremiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well aseligible under your employer plan, your employer must allow you to enroll in your employer planif you aren’t already enrolled. This is called a “special enrollment” opportunity, and you mustrequest coverage within 60 days of being determined eligible for premium assistance. If you havequestions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
Your Rights & Protections Against Surprise Medical BillsWhen you get emergency care or are treated by an out-of-network provider at an in-network hospitalor ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t becharged more than your plan’s copayments, coinsurance and/or deductible. What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service. You’re protected from balance billing for: Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia,pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.These providers can’t balance bill you and may not ask you to give up your protections not to bebalance billed. If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
Your Rights & Protections Against Surprise Medical Bills ContinuedYou’re only responsible for paying your share of the cost (like the copayments, coinsurance, Generally, your health plan must: Cover emergency services without requiring you to get approval for services in advance(also known as “prior authorization”). Cover emergency services by out-of-network providers. Base what you owe the provider or facility (cost-sharing) on what it would pay an in-networkprovider or facility and show that amount in your explanation of benefits. Count any amount you pay for emergency services or out-of-network services toward yourin-network deductible and out-of-pocket limit. You’re never required to give up your protections from balance billing. You also aren’trequired to get out-of-network care. You can choose a provider or facility in your plan’snetwork. When balance billing isn’t allowed, you also have these protections: and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. If you think you’ve been wrongly billed, contact: 1-800-985-3059 Visitwww.cms.gov/nosurprises/consumers for more information about your rights under federal law. Wellness Program NoticeYour health plan is committed to helping you achieve your best health. Rewards for participating ina wellness program are available to all employees. If you think you might be unable to meet astandard for a reward under this wellness program, you might qualify for an opportunity to earn thesame reward by different means. Contact us and we will work with you (and, if you wish, with yourdoctor) to find a wellness program with the same reward that is right for you in light of your healthstatus.