employee benefits guide - goodwill central texas · 2018. 1. 1. · goodwill advocacy 888-517-2454...
TRANSCRIPT
2018
Employee Benefits Guide January 1, 2018 - December 31, 2018
Table of Contents
Customer Service and Contact Information
3
Eligibility, Enrollment and Useful Benefit Terms 4
Medical Plan Chart 5-6
Medical Rates 7
Medical Plan Details 8-14
Dental Plan Benefits & Rates 15
Vision Plan Benefits & Rates 16
Basic Life and AD&D Plan Benefits 17
Voluntary Life & AD&D Benefits 18
Voluntary Life & AD&D Rates 19-22
Short & Long Term Disability Benefits & Rates 23-28
Flexible Spending Account (FSA) 29
Required Annual Employee Notices Appendix
**If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives you more choices about your prescription drug coverage. Please see the back of this guide for more details.
This document is an outline of the coverage proposed by the carrier(s). It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Your full Summary Plan Document (SPD) is made available through your Human Resources Department.
The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific coverage issues can be directed to the Benefit Advocates at CLS Partners Customer Service at 512-306-9300 or via e-mail at [email protected]
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Customer Service and Contact Information
Who to call when you have a question about benefits?
Goodwill Advocacy 888-517-2454 [email protected]
CLS Support
Cindy Adams
855-889-3713
512-637-7549
Benefit Carrier Customer Service Website
Medical/Rx Drugs (in-network verification through Setton/Cigna))
Seton/Cigna
844-883-2422
www.MySetoninsurance.com
Health Reimbursement Account
Flexible Spending Account
Significa
Significa
800-433-3786
800-433-3786
www.significabenefits.com
www.significabenefits.com
Dental Basic Life and AD&D Voluntary Life and AD&D Auto/Home Insurance Quotes
Metlife
800-942-0854
www.metlife.com
Wills (available w/ MetLife) Hyatt Legal Plans
800-821-6400 www.legalplans.com
Vision Cigna 877-478-7557 myCigna.com
Short Term Disability Long Term Disability
UNUM
800-275-8686
www.unum.com
403(b) Newport Group 800-217-2240 www.newportgroup.com
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Eligibility, Enrollment and Useful Benefit Terms
The new benefit plan will be effective January 1, 2018 - December 31, 2018.
New employees are effective on the 1st of the month
following 60 days from their date of hire.
You are eligible for benefits if you are a full-time employee that regularly works at least an average of 30 hours a week.
Open enrollment applies to Medical, Dental, Vision, Voluntary Life and AD&D, FSA, Voluntary STD, and Voluntary LTD Coverage.
The open enrollment period is the only time employees may enroll in the above listed coverage without the occurrence of a qualifying event (see definition below).
Making Enrollment Changes During the Year: In most cases, your benefit elections will remain in effect for the entire plan year (January 1st - December 31st). During the annual enrollment period, you have the opportunity to review your benefit elections and make changes for the coming year.
You may only make changes to your elections during the year if you have one of the following status changes:
Marriage, divorce or legal separation (if your state recognizes legal separation);
Gain or loss of an eligible dependent for reasons such as birth, adoption, court order, disability, death; reaching the dependent child age limit; or
Significant changes in employment or employer- sponsored benefit coverage that affect you or your spouse’s benefit eligibility.
Your benefit change must be consistent with your change in family status.
IRS regulations require that for enrollment due to the qualifying events above, change forms must be submitted within 30 days of that qualifying event. Contact your Human Resources office for information on completing these forms.
Calendar Year Deductible and Out-of-Pocket Maximum: Expenses incurred towards your annual deductible and your out-of-pocket maximum are credited on a calendar year basis. A calendar year is January 1st - December 31st. Your deductible and out-of-pocket maximum will restart January 1st each year, regardless of the expenses you incurred in the prior calendar year or when your annual open enrollment period occurs.
Primary Care Physicians/Specialty Physician Referrals: You are NOT required to select a primary care physician (PCP) or obtain referrals for specialty physicians. Be sure that all providers (doctors, labs, x-rays, etc.) participate in-network for the best coverage.
Dependent Age Limitation: Your children are eligible for coverage on your medical, dental, vision and voluntary life and AD&D plan until age 26; regardless of marital, student or financial status.
In-Network vs. Out-of-Network Benefits: Goodwill Industries of Central Texas’s medical plans offer in-network coverage only. When a doctor or hospital agrees to be in the Plan’s network, they are contractually bound not to charge over a specific amount for services covered by the Plan. When you choose an in-network provider, they will file a claim on your behalf and you are not held responsible for amounts that the provider may charge in excess of their contracted rates.
The medical plans do not offer Out-of-Network coverage. By seeing a provider that is out-of-network, the claim will not be paid and the member will be billed 100% for the services provided.
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Medical Plans Medical Plan Information
Cigna Seton Customer Service: 844-883-2422
Group # SIK001700
Network: Performance/Performance Plus
The following comparison chart reflects In-Network coverage only.
Tier 1 Base Plan Buy-Up Plan Seton Insurance Seton Insurance
In-Network Only In-Network Only
Annual Deductible $5,000 Individual
$10,000 Family
Annual Out-of-pocket Maximum
$6,850 Individual
$13,700 Family
Co-insurance 100% after deductible
Significa Debit Card / Health Reimbursement Account (HRA)
$1,000 Individual $2,000 Family
$3,000 Individual $6,000 Family
Emergency Room 100% after deductible
Urgent Care Center 100% after deductible
Physician Visits
Primary Care 100% after deductible
Physician Specialist 100% after deductible
Preventive Care 100%
Diagnostic Lab and X-Ray - Outpatient
100% after deductible
Major Diagnostic (Freestanding
Facility) (CT, PET, MRI, MRA ) 100% after deductible
Prescriptions Some prescriptions that are related to disease or condition management (diabetes, asthma, blood pressure, etc.) may be available with no out-of-pocket expense. For a list of qualifying medications, contact the Benefits Manager.
AFTER DEDUCTIBLE Prescriptions
Generic $10 copay
Preferred Brand Name $25 copay
Non-Preferred Brand Name 30%
Specialty 30%
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St. David’s / Heart Hospital of Austin (Tier 2)
Tier 2 Base Plan Buy-Up Plan
Seton Insurance Seton Insurance
Annual Deductible $5,000 Individual
$10,000 Family
Annual Out-of-pocket Maximum
$6,850 Individual
$13,700 Family
Inpatient Hospital at St. David’s or Heart Hospital of Austin
After deductible is met: $1,500 copay then Cigna pays 50%
Outpatient Facility through St. David’s or Heart Hospital of Austin
After deductible is met; $500 copay then Cigna pays 50%
Coinsurance 50% after deductible
Out of Network Coverage NONE
Medical Plan
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Medical Rates
BASE PLAN
Goodwill Pays
Monthly Employee Pays
Monthly Employee Pays
Bi-Weekly
Employee Only: $312.12 $18.00 $9.00
Employee + Spouse: $594.82 $57.18 $28.59
Employee + Child(ren): $502.51 $42.20 $21.10
Employee + Family: $900.74 $99.98 $49.99
BUY-UP PLAN
Goodwill Pays
Monthly Employee Pays
Monthly Employee Pays
Bi-Weekly
Employee Only: $467.01 $159.68 $79.84
Employee + Spouse: $953.16 $351.30 $175.65
Employee + Child(ren): $791.11 $287.43 $143.72
Employee + Family: $1,463.86 $574.86 $287.43
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Medical Plan Details In 2018 Goodwill Central Texas will continue the medical plans through Seton/Cigna.
How do I access my medical benefits?
1. Present both your Seton ID Card and your HRA debit card to the provider/pharmacy at the time of service. Below is a SAMPLE of the Seton ID Card you will receive.
2. Providers can verify your medical benefits by calling the number on your ID card at 844-883-2422. Hours of service are Monday-Friday 6am to 7pm and Saturday 9am to 1pm.
3. When you have met your deductible, Seton/Cigna will then pay medical expense costs.
4. You will be provided a Health Reimbursement Account (HRA) debit card - (see card below) to pay a portion
of medical costs ($1,000 for the Base Plan, or $3,000 for the Buy Up Plan). This is a credit/debit card to be used for medical/prescription purposes only and only the dependents on the medial plan can use the HRA debit card. Once funds are used in this account you are responsible for any costs thereafter.until the deductible has been met.
5. For balance or information on your HRA please call (800) 433-3786.
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Medical Plan Details
Medical Plan Details
Base Plan Seton Insurance w/ HRA Debit Card
Single
• HRA (debit card) Pays First $1,000
• You Pay Next $4,000
• Seton Insurance then pays 100% for all claims except Rx and St. David’s copays
Family
• HRA (debit card) Pays First $2,000 • You Pay Next $8,000 • Seton Insurance then pays 100% for all
claims except Rx & St. David’s copays
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Medical Plan Details
Buy-Up Plan Seton Insurance w/ HRA Debit Card
Single
• HRA (debit card) Pays First $3,000
• You Pay Next $2,000
• Seton Insurance then pays 100% for all claims except Rx and St. David’s copays
Family
• HRA (debit card) Pays First $6,000 • You Pay Next $4,000 • Seton Insurance then pays 100% for all
claims except Rx & St. David’s copays
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Medical Plan Details
Nurse Line….24/7
• Call the Seton nurse advice line for health questions
• Call us 24/7/365 to speak to a registered nurse.
• The Seton nurse advice line is available at no extra cost to you and can help you make informed decisions about health issues you are experiencing at home or when to see a health care provider.
• Nurses can help you choose the right care in the right setting at the right time, whether it’s reviewing home treatment options or scheduling an appointment
• Call toll-free at 844-658-1708 or locally at 512-324-2338 to be
connected to the nurse line
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Medical Plan Details
when outside the Seton and Providence service area.
Away from home care
Emergency care is always covered at the in-network
benefit level - even if it’s not from an in-network provider
(deductible and copay/coinsurance applies).
Emergency care
Customers have access to the Cigna Open Access Plus
national network when outside the Seton and
Providence service area
Open Access Plus*
Away from Home Care When customers enrolled in a Seton Performance plan travel outside of the
Austin/Waco service area and receive medical services, customers have access to the Cigna Open Access Plus network.
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Medical Plan Details
How to find a provider
• How to find a provider go to:
www.setoninsurance.com/provider
• Call Seton Insurance: Monday through Friday, 6 a.m. to 7 p.m. or Saturday 9 a.m. to 1 p.m. (CDT)
• 844-883-2422 to speak with a live customer service representative
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Medical Plan Details
In-Network Hospitals
Tier 1 - Seton
Seton Edgar B Davis Luling, TX
Seton Smithville Regional Smithville, TX
Seton Highland Lakes Burnet, TX
Seton Medical Center Harker Heights Killeen, TX
Coryell Memorial Gatesville, TX
Seton Medical Center Kyle, TX
Seton Medical Center Williamson Round Rock, TX
Seton Southwest Austin, TX
Cedar Park Regional Medical Center Cedar Park, TX
University Medical Center at Brackenridge Austin, TX
Dell Children’s Medical Center of Central Texas Austin, TX
Seton Medical Center Austin, TX
Seton Northwest Austin, TX
Tier 2 – St. David’s*
St. David’s Georgetown Hospital Georgetown, TX
St. David’s Round Rock Medical Center Round Rock, TX
St. David’s Medical Center Austin, TX
St. David’s South Austin Medical Center Austin, TX
St. David’s North Austin Medical Center Austin, TX
Heart Hospital of Austin Austin, TX
*See page 6 for benefit coverages/additional costs for St. David’s facilities.
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Dental Plan Summary
Dental Plan Information MetLife
Claims, Benefits: www.metlife.com Customer Service: 800-942-0854
Group No. 144146 Network: PDP Plus
While there is a network of providers you can utilize, benefit percentages are the same regardless of whether you visit an in-network or out-of-network provider. Utilizing an in-network provider will result in a lower patient responsibility overall. Out-of-Network benefits are subject to Reasonable and Customary charges and you may be balance billed if your dentist charges above this amount.
Dental Rates
Rate Type Employee Pays
Monthly Employee Pays
Bi-Weekly
Employee Only: $27.02 $13.51
Employee + Spouse: $52.40 $26.20
Employee + Child(ren): $51.22 $25.61
Employee + Family: $79.30 $39.65
Dental Benefits MetLife Dental Benefits
Type I - Preventive Services Oral examinations, x-rays, cleanings
100% - no deductible
Type II - Basic Services Fillings, simple extractions
80% after deductible
Type III - Major Services Crowns, bridges, dentures, root canal
50% after deductible
Annual Deductible (waived for Type I)
$50 Individual $150 Family
Annual Maximum per Person
$1,250
Orthodontia
Not Covered
One Year Late Entrant Waiting Period Applies
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Vision Plan Summary
Vision Plan Information Cigna
Claims, Benefits: myCigna.com Customer Service: 877-478-7557
Group #:3340695
Vision Benefits In-Network Non-Network
Eye Exam $10 Copay Up to $45
Frames/Lenses $25 Copay See frame and lenses
Single Vision Included in Prescription Up to $32
Bifocal Lenses Included in Prescription Up to $55
Lined Trifocal Lenses Included in Prescription Up to $65
Frames $130 Allowance Up to $80
Contact Exam $0 Copay Up to $105
Contact Lenses $130 Allowance
Exam Frequency 12 Months
Lens Frequency 12 Months
Frames Frequency 12 Months
Please review your plan document for an exact description of the services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
Vision Rates
Rate Type Employee Pays
Monthly Employee Pays Bi-
Weekly
Employee Only: $5.10 $2.55
Employee + Spouse: $10.21 $5.11
Employee + Child(ren): $10.92 $5.46
Employee + Family: $17.80 $8.90
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Basic Life/AD&D Plan Summary
Basic Life and AD&D Plan Information MetLife
Claims, Benefits: www.metlife.com Customer Service: 800-942-0854
Group No. 144146
Goodwill Industries of Central Texas offers Basic Term Life and Accidental Death and Dismemberment (AD&D) insurance to all full-time active employees working at least 30 hours per week.
This plan is paid 100% by Goodwill Industries of Central Texas.
Basic Life and AD&D Benefits
Full-Time Employee’s Life Benefit
1x Base Annual Earnings to a maximum of $250,000
Age Reduction Schedule
65% at Age 65 50% at Age 70
Accidental Death & Dismemberment (AD&D)
Equal to Life Amount
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Voluntary Life & AD&D Summary Voluntary Life and AD&D Information
MetLife Claims, Benefits:www.metlife.com Customer Service: 800-942-0854
Group No. 144146
All active, full-time employees of Goodwill Industries of Central Texas and their dependents are eligible for Voluntary Life and Accident Death and Dismemberment (AD&D) benefits provided by MetLife. Will preparation is available at no charge.
This plan is 100% paid by the Employee.
MetLife Voluntary Life and AD&D Benefits
Employee Life and AD&D Amount Lesser of 5x annual salary up to $500,000
*Employee Guarantee Issue Amount
$250,000*
Spouse Life Amount
Maximum of $100,000 (not to exceed 50% of Employee’s amount)
*Child Life Amount Live Birth to 6 Months: $1,000 6 Months to Age 26: $10,000
Evidence of Insurability Required if plan has not been previously elected
*Guarantee Issue amounts listed are only available to new hires, their spouses and their children after the initial offer- ing. All other eligible employees and spouses will be required to submit Evidence of Insurability for any new coverage amount or increase in coverage amount.
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Voluntary Life Rates
19
16
Voluntary Life Rates
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17
Voluntary Life Rates
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Voluntary Accidental Death & Dismemberment (AD&D) Rates
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Short-Term and Long-Term Disability Summary STD & LTD Plan Information
Unum Claims, Benefits: www.unum.com Customer Service: 800-275-8686
Group No. 0931548-001
Short-Term Disability Insurance* Short-term disability (STD) insurance provides partial income if you become disabled due to an injury or illness. Unum provides STD coverage. Benefits begin on the 15th day of any injury, hospitalization or illness and provide 60% of your pay, up to $1,000 per week. STD benefits can continue for up to 11 weeks. There is a 14-day waiting period before STD payments begin. Long-Term Disability Insurance* Meeting your basic living expenses can be a real challenge if you become disabled for a long period. Your options may be limited to personal savings, spousal income and possibly Social Security. Disability insurance provides protection for your most asset and your ability to earn an income. Your LTD coverage provides income when you have been disabled for 90 days or more (after STD benefits run out). Your benefit is 60% of your pay, up to $10,000 per month. Benefits may last until you are no longer disabled or reach the Social Security normal retirement age. Rates for Short-Term and Long-Term Disability can be found on the following 5 pages. *If you waived STD/LTD when initially offered and you choose to enroll at Open Enrollment, you will need to complete an Evidence of Insurability form.
Unum Short-Term Disability (STD) Benefits
Weekly Benefit
60% of Weekly Income
Maximum Weekly Benefit
$1,000
Elimination Period
14 Days
Maximum Benefit Duration
Social Security National Retirement Age (SSNRA)
Own Occupation Limitation
24 Months
Mental Health Limitation
12 Months
Substance Abuse
Limitation
12 Months
Pre-Existing Limitation
6/12/24
Cost per Pay period
See Rates on following
pages
Unum Long-Term Disability (LTD) Benefits
Monthly Benefit
60% of Monthly Income
Maximum Monthly Benefit
$10,000
Elimination Period
90 Days or until end of the
STD max benefit period
Maximum Benefit Duration
Social Security National Retirement Age (SSNRA)
Own Occupation Limitation
24 Months
Mental Health Limitation
12 Months
Substance Abuse
Limitation
12 Months
Pre-Existing Limitation
6/12/24
Cost per Pay period
See Rates on following
pages
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Voluntary Short-Term Disability (STD) Rates
24
Voluntary Long-Term Disability (LTD) Rates
25
24
Voluntary Long-Term Disability (LTD) Rates
26
Voluntary Long-Term Disability (LTD) Rates
27
26
Voluntary Long-Term Disability (LTD) Rates
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Flexible Spending Account (FSA)
What Is a Flexible Spending Account? A Flexible Spending Account is designed exclusively for employees, and is established by your employer under Section 125, 129, 132f or 105 of the Internal Revenue Code. This plan allows a participating employee to take certain expenses from their paycheck on a pre-tax basis. This means that all amounts deducted from your paycheck and contributed toward your plan will not be subject to Federal Income tax, nor will it be subject to Social Security tax.
What are eligible expenses under the plan?
Premium Payments Allows you to use pre-tax rather than after-tax dollars to pay for your share of employer sponsored insurance premiums (medical, dental and vision). Premium payment is a simple payroll adjustment which is handled internally by your employer’s payroll department. Do not add premium contributions to your medical expense account contributions.
Medical Expenses (Paid By the Employee) An employee’s out-of-pocket health care expenses can be paid with before-tax dollars when an employee elects to deposit some of those dollars into their Medical Expense Reimbursement Account. The amount the employee elects to set aside in this account will be held until he or she submits receipts for eligible expenses to be reimbursed. The maximum amount an employee can elect is $2,600 for the 2018 plan year. Eligible expenses can include (not limited to*:
Above Usual & Customary Charges Chiropractor Psychologist Co-insurance Deductibles Physical Exams Dental Expenses Eyeglasses & Contact Lenses Hearing Aids Special Medical Equipment Prescribed Birth Control Pre-Existing Conditions
*For a complete list of eligible expenses please see IRS Publication 502.
Use It Or Lose It Provision Unused balances at the end of the plan year cannot be carried over into the following plan year (the plan year is January 1
st – December 31
st). Your annual election must be used by the end of the plan year or any remaining balance will
be forfeited. You should plan cautiously in order to avoid forfeiting your money at the end of the plan year.
Dependent Care (must be work related) Another important part of the Flexible Spending Account is the ability to pay for child care or day care services with before-tax dollars. Your savings will amount to 22% to 35% of your actual child care expense, depending on your individual or family tax brackets. The maximum amount an employee can elect is $5,000 per plan year, per family. Eligible expenses can include:
Nursery, Baby-Sitting, Private Pre-K, Extended Day Care before & after school
Note: If you are a highly compensated employee, Goodwill Industries of Central Texas may be required to discontinue or limit your contributions to the Dependent Care Reimbursement account in order to comply with certain nondiscrimination requirements applicable to the plan under tax law. You will be notified if you are affected by this rule. Please see your Human Resources Department if you have any questions. Employees should be aware that if you elect the Dependent Care Reimbursement Account at any time, your election cannot exceed the IRS limitation of $5,000 per Calendar year. You will be required to coordinate your total payroll deductions to accommodate this IRS limitation. In addition, the IRS limits your elections and or changes to only the open enrollment period unless you have a qualifying event.
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Annual Notices
May, 2014
Required Annual Employee Notices
This document contains required notices as you are eligible for or enrolled in certain health and welfare plans. It contains the following:
Newborn’s Act Disclosure Women’s Health and Cancer Rights Act of 1998 (WHCRA) Michelle’s Law Premium assistance under Medicaid and Children’s Health Insurance Program HIPAA Notices Notice of Availability for HIPAA/Notice of Privacy Practices Notice of COBRA Continuation Coverage Rights Notice of Creditable Coverage Under Medicare Part D
Unless stated, if you have questions or concerns about any of these documents you can contact your plan administrator.
Name of Entity/Sender Goodwill Industries of Central TexasContact-Position/Office Cindy Adams, Benefits Manager
Address 1015 Norwood Park Blvd., Austin, TX Phone Number 512-637-7549
We advise that you maintain a copy of these notices in a place where you can find them. They contain information regarding your health plans and other government programs that may impact the availability and cost of health care both now as an employee and in the future.
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 varies based on the information collected. 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, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number.
Annual Notices
May, 2014
Newborn’s Act Disclosure - 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 mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). 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 not in excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act of 1998 (WHCRA) - Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema?
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; and 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, please contact your plan administrator.
Name of Entity/Sender Goodwill Industries of Central TexasContact-Position/Office Cindy Adams, Benefits Manager
Address 1015 Norwood Park Blvd., Austin, TX 78753 Phone Number 512-637-7549
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‐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 August 10, 2017. Contact your State for more information on eligibility –
ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Phone: 1‐855‐692‐5447
Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1‐877‐357‐3268
ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1‐866‐251‐4861 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.asp x
Website: http://dch.georgia.gov/medicaid ‐ Click on Health Insurance Premium Payment (HIPP) Phone: 404‐656‐4507
ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Phone: 1‐855‐MyARHIPP (855‐692‐7447)
Healthy Indiana Plan for low‐income adults 19‐64 Website: http://www.in.gov/fssa/hip/ Phone: 1‐877‐438‐4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1‐800‐403‐0864
COLORADO – Health First Colorado (Colorado’s Medicaid Program) &
Child Health Plan Plus (CHP+)
IOWA – Medicaid
Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1‐800‐221‐3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child‐Health‐Plan‐Plus CHP+ Customer Service: 1‐800‐359‐1991/ State Relay 711
Website: http://dhs.iowa.gov/ime/members/medicaid‐a‐to‐ z/hipp Phone: 1‐888‐346‐9562
KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1‐785‐296‐3512
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603‐271‐5218
KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://chfs.ky.gov/dms/default.htm Phone: 1‐800‐635‐2570
Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609‐631‐2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1‐800‐701‐0710
LOUISIANA – Medicaid NEW YORK – Medicaid Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1‐888‐695‐2447
Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1‐800‐541‐2831
MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public‐ assistance/index.html Phone: 1‐800‐442‐6003 TTY: Maine relay 711
Website: https://dma.ncdhhs.gov/ Phone: 919‐855‐4100
MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: http://www.mass.gov/eohhs/gov/departments/masshe alth/ Phone: 1‐800‐862‐4840
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid / Phone: 1‐844‐854‐4825
MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://mn.gov/dhs/people‐we‐ serve/seniors/health‐care/health‐care‐ programs/programs‐and‐services/medical‐ assistance.jsp Phone: 1‐800‐657‐3739
Website: http://www.insureoklahoma.org Phone: 1‐888‐365‐3742
MISSOURI – Medicaid OREGON – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp. htm Phone: 573‐751‐2005
Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index‐es.html Phone: 1‐800‐699‐9075
MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HI PP Phone: 1‐800‐694‐3084
Website: http://www.dhs.pa.gov/provider/medicalassistance/he althinsurancepremiumpaymenthippprogram/index.ht m Phone: 1‐800‐692‐7462
NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632‐7633 Lincoln: (402) 473‐7000 Omaha: (402) 595‐1178
Website: http://www.eohhs.ri.gov/ Phone: 855‐697‐4347
NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: https://dwss.nv.gov/ Medicaid Phone: 1‐800‐992‐0900
Website: https://www.scdhhs.gov Phone: 1‐888‐549‐0820
SOUTH DAKOTA - Medicaid WASHINGTON – MedicaidWebsite: http://dss.sd.gov Phone: 1‐888‐828‐0059
Website: http://www.hca.wa.gov/free‐or‐low‐cost‐ health‐care/program‐administration/premium‐payment‐ program
Phone: 1‐800‐562‐3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – MedicaidWebsite: http://gethipptexas.com/ Phone: 1‐800‐440‐0493
Website: http://mywvhipp.com/ Toll‐free phone: 1‐855‐MyWVHIPP (1‐855‐699‐8447)
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIPMedicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1‐877‐543‐7669
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.p df Phone: 1‐800‐362‐3002
VERMONT– Medicaid WYOMING – MedicaidWebsite: http://www.greenmountaincare.org/ Phone: 1‐800‐250‐8427
Website: https://wyequalitycare.acs‐inc.com/ Phone: 307‐777‐7531
VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance. cfm
Medicaid Phone: 1‐800‐432‐5924 CHIP Website: http://www.coverva.org/programs_premium_assistance. cfm CHIP Phone: 1‐855‐242‐8282
To see if any other states have added a premium assistance program since August 10, 2017, 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/agencies/ebsa www.cms.hhs.gov 1‐866‐444‐EBSA (3272) 1‐877‐267‐2323, Menu Option 4, Ext. 61565
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 [email protected] and reference the OMB Control Number 1210‐0137.
OMB Control Number 1210‐0137 (expires 12/31/2019)
HIPAA Notices
Oct. 2017
Special Enrollment - 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 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 you 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 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.
Your group health plan will allow an employee or dependent who is eligible, but not enrolled, for coverage to enroll for coverage if either of the following events occurs:
1. TERMINATION OF MEDICAID OR CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) COVERAGE – If the employee or dependent is covered under a Medicaid plan or under a State child health plan and coverage of the employee or dependent under such a plan is terminated as a result of loss of eligibility.
2. ELIGIBILITY FOR EMPLOYMENT ASSISTANCE UNDER MEDICAID OR CHIP – If the employee or dependent becomes eligible for premium assistance under Medicaid or a State child health plan, including under any waiver or demonstration project conducted under or in relation to such a plan. This is usually a program where the state assists employed individuals with premium payment assistance for their employer’s group health plan rather than direct enrollment in a state Medicaid program.
To be eligible for this special enrollment opportunity you must request coverage under the group health plan within 60 days after the date the employee or dependent becomes eligible for premium assistance under Medicaid or CHIP or the date your or your dependent’s Medicaid or state-sponsored CHIP coverage ends.
Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may not keep you (or your dependents) out of the plan based on anything related to your health. In addition, a group health plan may not charge you (or your dependents) more for coverage, based on health, than the amount charged a similarly situated individual.
The Genetic Information Nondiscrimination Act (GINA). The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits discrimination in group health plan coverage based on genetic information. It expands the genetic information protections included in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and prevents a plan or issuer from imposing a pre-existing condition exclusion provision based solely on genetic information, and prohibits discrimination in individual eligibility, benefits, or premiums based on any health factor (including genetic information). GINA also generally prohibits plans and issuers from requesting or requiring an individual to undergo a genetic test and from collecting genetic information (including family medical history) prior to or in connection with enrollment, or for underwriting purposes.
HIPAA Notices
Oct. 2017
Right to individual health coverage. Under HIPAA, if you are an “eligible individual”, you have a right to buy certain individual health policies (or in some states, to buy coverage through a high-risk pool) without a pre-existing condition exclusion. To be an eligible individual, you must meet the following requirements:
You have had coverage for at least 18 months without a break in coverage of 63 days or more; Your most recent coverage was under a group health plan; Your group coverage was not terminated because of fraud or nonpayment of premiums; You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits (or
continuation coverage under a similar state provision); and You are not eligible for another group health plan, Medicare, or Medicaid, and do not have any other health
insurance coverage.
The right to buy individual coverage is the same whether you are laid off, fired, or quit your job.
Therefore, if you are interested in obtaining individual coverage and you meet the other criteria to be an eligible individual, you should apply for this coverage as soon as possible to avoid losing your eligible individual status due to a 63-day break.
Special information for people on FMLA leave. If you are taking leave under the Family and Medical Leave Act (FMLA) and you drop health coverage during your leave, any days without health coverage while on FMLA leave will not count toward a 63-day break in coverage. In addition, if you do not return from leave, the 30-day period to request special enrollment in another plan will not start before your FMLA leave ends.
Therefore, when you apply for other health coverage, you should tell your plan administrator or health insurer about any prior FMLA leave.
Notice of Availability for HIPAA/Notice of Privacy Practices. Goodwill Industries of Central Texas would like to communicate the availability of its Notice of Privacy Practices. At any time, a copy of the current Notice of Privacy Practices may be obtained by contacting Human Resources at 512-637-7549.
For more information. If you have questions about your HIPAA rights, you may contact your state insurance department or the U.S. Department of Labor, Employee Benefits Security Administration (EBSA), toll-free at (866) 444-3272 (for free HIPAA publications ask for publications concerning changes in health care laws). You may also contact the CMS publication hotline at (800) 633-4227 (ask for Protecting Your Health Insurance Coverage). These publications and other useful information are also available on the Internet at: http://www.dol.gov/ebsa, the DOL’s interactive Web pages - Health Elaws, or http://www.cms.hhs.gov/healthinsreformforconsume/.
Notice of COBRA Continuation Coverage Rights **Continuation Coverage Rights Under COBRA**
OMB Control Number 1210-0123 (expires 12/31/2019) Oct 2017
Introduction
You are receiving this notice because you have recently gained coverage under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
What is COBRA continuation coverage?
COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:
The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the plan as a “dependent child.”
When is COBRA continuation coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:
The end of employment or reduction of hours of employment; Death of the employee; The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
Notice of COBRA Continuation Coverage Rights **Continuation Coverage Rights Under COBRA**
OMB Control Number 1210-0123 (expires 12/31/2019) Oct 2017
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 30 days after the qualifying event occurs.
How is COBRA continuation coverage provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event during the 18 month of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
Are there other coverage options besides COBRA continuation coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.healthcare.gov.
Keep Your Plan informed of address changes
To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Plan contact information
Name of Entity/Sender Goodwill Industries of Central Texas
Contact-Position/Office Address
Phone Number
Cindy Adams, Benefits Manager 1015 Norwood Blvd., Austin, TX 78753 512-637-7549
Important Notice from Goodwill About Your Prescription Drug Coverage and Medicare
OMB control number 0938-0990 Oct 2017
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Goodwill Industries of Central Texas 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. Goodwill Industries of Central Texas has determined that the prescription drug coverage offered by the Goodwill Medical 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 15th to December 7th.
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 Goodwill coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Goodwill coverage, be aware that you and your dependents may 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 Goodwill Industries of Central Texas 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 Goodwill Industries of Central Texas changes. You also may request a copy of this notice at any time.
Important Notice from Goodwill About Your Prescription Drug Coverage and Medicare
OMB control number 0938-0990 Oct 2017
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 (800) MEDICARE/(800) 633-4227); TTY users should call (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 at www.socialsecurity.gov Call them at (800) 772-1213; TTY (800) 325-0778.
Plan Administrator contact information
Date January 1, 2018Name of Entity/Sender Goodwill Industries of Central Texas
Contact--Position/Office Cindy Adams, Benefits Manager Address 1015 Norwood Park Blvd., Austin, TX 78753
Phone Number 512-637-7549
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).