Legal Notices

Consolidated Omnibus Budget Reconciliation Act (COBRA)

If you’re an employee with medical, dental, or vision coverage through CHOC, you have the right to choose continuation coverage if you lose your group health coverage due to reduction in your hours of employment or the termination of your employment for reasons other than gross misconduct.

Your eligible dependents may also have the right to elect and pay for continuation of coverage for a temporary period in certain circumstances where coverage under the plan would otherwise end, such as divorce, or dependent children who no longer meet eligibility requirements.

Important Note: This brief summary of the right you and your dependents have to continue insurance is not intended as the official notice of your rights required by federal and state law. We’ve included this brief summary to inform you that you have these rights. You’ll receive a separate, detailed explanation of your right to continue health insurance coverage when applicable.

Notice of Availability of HIPAA Privacy Notice

Under the Health Insurance Portability and Accountability Act (HIPAA), you may request a copy of the HIPAA Privacy Notice directly from the insurance carriers.

Special Enrollment Events

Special enrollment events allow you and your eligible dependents to enroll for health coverage outside the Open Enrollment period under certain circumstances if you lose eligibility for other coverage, become eligible for state premium assistance under Medicaid or the Children’s Health Insurance Program (CHIP), or acquire newly eligible dependents. This is required under the Health Insurance Portability and Accountability Act (HIPAA).

If you decline enrollment in a CHOC medical plan for you or your dependents (including your spouse/domestic partner) because of other health insurance coverage or group health plan coverage, you or your dependents may be able to enroll in a CHOC medical plan without waiting for the next Open Enrollment period if you:

• Lose other health insurance or group health plan coverage. You must request enrollment within 30 days after the loss of other coverage
• Gain a new dependent as a result of marriage, birth, adoption or placement for adoption. You must request health plan enrollment within 30 days after the marriage, birth, adoption or placement for adoption
• Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical plan enrollment within 60 days after the loss of such coverage

If you timely request a change due to a special enrollment event, coverage will be effective the date of birth, adoption or placement for adoption.  For all other events, coverage will be effective the first of the month following your timely request for enrollment.  In addition, you may enroll in a CHOC medical plan if you become eligible for a state premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days after you gain eligibility of medical plan coverage. If you request this change, coverage will be effective the first of the month following your request for enrollment.  Specific restrictions may apply, depending on Federal and state law.

Women’s Health and Cancer Rights Act of 1998

The Women’s Health and Cancer Rights Act (WHCRA) requires employer groups to notify participants and beneficiaries of the group health plan of their rights to mastectomy benefits under the plan. For individual 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 all stages of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductible and co-insurance provisions that apply for the mastectomy. For deductibles and coinsurance information applicable to the plan in which you enroll, please refer to the plan descriptions.

Newborn’ and Mothers’ Health Protection Act Notice

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) after delivery.  In any case, plans and insurance carriers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance carrier for prescribing a length of stay not in excess of 48 (or 96) hours.

Creditable Prescription Drug Coverage and Medicare

If you or your covered dependent(s) are enrolled in any prescription drug coverage under one of CHOC’s medical plans and are or become covered by Medicare, you may decide to enroll in a Medicare prescription drug plan later and not be subject to a late enrollment penalty—as long as you had creditable coverage within 63 days of your Medicare prescription drug plan enrollment. “Creditable coverage” is when the prescription drug coverage under the CHOC medical plans is expected to pay out, on average, at least as much as the standard Medicare prescription drug coverage will pay. If you or your family members aren’t currently covered by Medicare and won’t become covered by Medicare in the next 12 months, this notice doesn’t apply to you.

You may have heard about Medicare’s prescription drug coverage, (called Part D), and wondered how it would affect you. Prescription drug coverage is available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans also offer more coverage for a higher monthly premium.

Individuals can enroll in a Medicare prescription drug plan when they first become eligible, and each year from October 15 through December 7. Individuals leaving employer coverage may be eligible for a Medicare Special Enrollment Period.

If you decide to enroll in a Medicare prescription drug plan and you’re an active employee or a family member of an active employee, you may also continue your employer coverage. In this case, the CHOC Medical plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan. If you waive or drop CHOC coverage, Medicare will be your only payer. You can re-enroll in the CHOC plan during Open Enrollment or if you have a special enrollment event for the CHOC plan.

You should know that if you waive or leave coverage with CHOC and you go 63 days or longer without creditable prescription drug coverage (once your applicable Medicare enrollment period ends), your monthly Part D premium will go up at least 1% per month for every month that you did not have creditable coverage. For example, if you go 19 months without coverage, your Medicare prescription drug plan premium will always be at least 19% higher than what most other people pay. You’ll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll in Part D.

More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. Medicare participants will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans.

Here’s how to get more information about Medicare prescription drug plans:

• Visit www.medicare.gov for personalized help.
• Call your State Health Insurance Assistance Program (see a copy of the Medicare & You handbook for the telephone number).
• Call (800) MEDICARE ((800) 633-4227). TTY users should call (877) 486-2048.

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov or call (800) 772-1213 (TTY: (800) 325-0778).

Affordable Care Act Physician Designation Notice

The Cigna HMO plans generally require the designation of a primary care provider. You have the right to designate any primary care provider who participates in the HMO plan’s network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider.

You do not need prior authorization from the HMO plan or from any other person (including a primary care provider) to obtain access to obstetrical or gynecological care from a health care professional in the HMO plan’s network who specializes in obstetrics or gynecology. The health care 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 a list of participating health care professionals who specialize in obstetrics or gynecology, go to www.mycigna.com. Until you make a designation, the HMO plan may designate one for you. For information on how to select a primary care provider and for a list of the participating primary care providers, go to www.mycigna.com.

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 July 31, 2021. Contact your state for more information on eligibility.

To see if any other states have added a premium assistance program since July 31, 2021, or for more information on special enrollment rights, contact either:To see if any other states have added a premium assistance program or for more information on special enrollment rights, contact either:

U.S. Department of Labor
Employee Benefits Security Administration
website: www.dol.gov/ebsa
(866) 444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services
website:  www.cms.hhs.gov
(877) 267-2323, Menu Option 4 Ext. 61565

Notice Informing Individuals About Nondiscrimination, Accessibility Requirements and Sample Nondiscrimination Statement

CHOC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.  CHOC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

CHOC:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages

If you need these services, contact the Human Resources Department.  If you believe that CHOC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Corporate Compliance at 877-388-8588 or at compliancehotline@choc.org.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html.