1. No category

Important Notices About Your
Group Health Plan Rights
Plan Year
May 1, 2015 to April 30, 2016
Date of Notice: March 18, 2015
Dan Williams Company
May 1, 2015 to April 30, 2016
The Federal Government requires Dan Williams Company to
notify employees of certain laws regarding their health plans.
This booklet contains the required notifications.
The notices provided on the following pages reflect the regulations and information
known on the date shown on the front page of this booklet.
However, federal rules and regulations may change, and your employer may decide to
make changes to your plan after the date of these notices. Any changes could affect the
content of these notices such as the Medicare Creditable Coverage Notices.
Please contact your employer if you have any questions about the notices.
Dan Williams Company
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May 1, 2015 to April 30, 2016
TABLE OF CONTENTS
Page
•
Health Insurance Marketplace Notice
4
•
ERISA Rights and Protections
6
•
Newborns’ & Mothers’ Health Protection Act
7
•
Women’s Health and Cancer Rights Act of 1998
7
•
Qualified Medical Child Support Order
8
•
Uniformed Services Employment and Reemployment
Rights Act (USERRA)
8
•
Notification of Rights Under Health Insurance
Portability and Accountability Act (HIPAA)
10
•
Notice of Continuation of Coverage Rights
11
•
Notice of Employee Rights and Responsibilities Under
the Family and Medical Leave Act
16
•
Notice of Privacy Practices
18
•
Premium Assistance Under Medicaid and Children’s
Health Insurance Program (CHIP)
23
•
Medicare Part D and Plan Prescription Drug Notice
27
Dan Williams Company
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May 1, 2015 to April 30, 2016
Health Insurance Marketplace Notice
General Information
There is a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you
evaluate options for you and your family, this notice provides some basic information about the
Marketplace and employment-based health coverage offered through Dan Williams Company.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your
budget. The Marketplace offers “one-stop shopping” to find and compare private health insurance
options. You may also be eligible for a new kind of tax credit that lowers your monthly premium
right away. Open enrollment for health insurance coverage through the Marketplace is November
15, 2014 through February 15, 2015.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does
not offer coverage, or offers coverage that doesn’t meet certain standards. The savings on your
premium that you’re eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you
will not be eligible for a tax credit through the Marketplace and may wish to enroll in your
employer’s health plan. However, you may be eligible for a tax credit that lowers your monthly
premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all
or does not offer coverage that meets certain standards. If the cost of a plan from your employer that
would
cover you (and not any other members of your family) is more than 9.56% of your household
income for the year, or if the coverage your employer provides does not meet the “minimum value”
standard set by the Affordable Care Act, you may be eligible for a tax credit.*
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage
offered by your employer, then you may lose the employer contribution (if any) to the employeroffered coverage. Also, this employer contribution—as well as your employee contribution to employer-offered coverage—is often excluded from income for Federal and State income tax purposes.
Your payments for coverage through the Marketplace are made on an after-tax basis.
*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the
total allowed benefit costs covered by the plan is no less than 60 percent of such costs.
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May 1, 2015 to April 30, 2016
Continued from Page 4
Health Insurance Marketplace Notice
How Can I Get More Information?
For more information about the coverage offered by your employer, please check your summary
plan description or contact your employer (see below).
The Marketplace can help you evaluate your coverage options, including your eligibility for
coverage through the Marketplace and its cost. Please visit www.healthcare.gov for more
information, including an online application for health insurance coverage and contact information
for a Health Insurance Marketplace in your area.
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.
Employer Name:
Dan Williams Company
Employer Identification Number (EIN): 74-2496879
Employer Address:
9050 N. Capital of Texas Hwy., #380
Austin, TX 78759
Employer Phone Number:
(512) 320-1410
Health Coverage Contact:
Jennifer Hartman
[email protected]
Here is some basic information about health coverage offered by this employer:
As your employer, we offer a health plan to all eligible employees.
With respect to dependents, we offer coverage to all eligible dependents.
This coverage meets the minimum value standard, and the cost of coverage to you is
intended to be affordable, based on employee wages.
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May 1, 2015 to April 30, 2016
The Employee Retirement Income Security Act of 1974 (ERISA)
As a participant in a benefit plan, you are entitled to certain rights and protections under ERISA.
ERISA provides that all participants shall be permitted to:
• Receive information about your plan and benefits;
• Examine, without charge, at the Plan Administrator’s office and at other specified
locations, such as worksites and union halls, all documents governing the plan,
including pertinent insurance contracts, trust agreements, collective bargaining
agreements, a copy of the latest summary annual report (Form 5500 Series), and other
documents filed by the plan with the Internal Revenue Service or the U.S. Department
of Labor and available at the Public Disclosure Room of the Employee Benefits Security
Administration;
• Obtain, upon written request to the Plan Administrator, copies of documents governing
the operation of a benefit plan, including insurance contracts and collective bargaining
agreements, and copies of the latest annual report (Form 5500 Series) and updated
Summary Plan Description(s);
• Receive a copy of the procedures used by the Plan for determining a qualified domestic
relations order (QDRO) or a qualified medical child support order (QMCSO).
Prudent Actions by Plan Fiduciaries
In addition to creating rights for participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your plan,
called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other
plan participants and beneficiaries. No one, including your employer, your union, or any other
person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining
a welfare benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know
why this was done, to obtain copies of documents relating to the decision without charge, and to
appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to
enforce the above rights. For instance, if you request a copy of plan documents or the latest annual
report and do not receive them within 30 days, you may file suit in a Federal court. In such a case,
the court may require the Plan Administrator to provide the materials and pay you up to $110 a day
until you receive the materials, unless the materials were not sent because of reasons beyond the
control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in
whole or in part, and you have exhausted the administrative remedies available under the benefit
plan, you may file suit in a State or Federal court. In addition, if you disagree with the decision or
lack thereof concerning the qualified status of a domestic relations order or a medical child support
order, you may file suit in Federal court.
Continued on Page 7
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May 1, 2015 to April 30, 2016
Continued from Page 6
If it should happen that the benefit plan fiduciaries misuse the benefit plan’s money, or if you are
discriminated against for asserting your rights, you may seek assistance from the U.S. Department of
Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and
legal fees. If you are successful, the court may order the person you have sued to pay these costs
and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds
your claim is frivolous.
Assistance with Your Questions
If you have any questions about a benefit plan, you should contact the Plan Administrator. If you
have any questions about this statement or about your rights under ERISA, or if you need assistance
in obtaining documents from the Plan Administrator, you should contact the nearest office of the
Employee Benefits Security Administration, U.S. Department of Labor listed in your telephone
directory or write to the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C.
20210. You may also obtain certain publications about your rights and responsibilities under ERISA
by calling the publications hotline of the Employee Benefits Security Administration at (866) 4443272.
The Newborns’ and Mothers’ Health Protection Act (Newborns’ Act)
The Newborns’ Act includes important protections for mothers and their newborn children with
regard to the length of the hospital stay following childbirth. The Newborns’ Act requires that group
health plans that offer maternity coverage pay for at least a 48-hour hospital stay following vaginal
delivery (96-hour stay in the case of Cesarean section). Additionally, a mother cannot be encouraged
to accept less than the minimum protections available to her under the Newborns’ Act, and an
attending provider cannot be induced to discharge a mother or newborn earlier than 48 or 96 hours
after delivery. However, federal law generally does not prohibit the mother’s or her 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).
A plan or issuer may not, under federal law, require that you, your physician, or other health care
provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). You
may be required, however, to obtain precertification for any days of confinement that exceed 48
hours (or 96 hours). For information on precertification, contact your Plan Administrator.
Women’s Health and Cancer Rights Act of 1998
The Women’s Health and Cancer Rights Act of 1998 requires that if you had or are going to have a
mastectomy, you may be entitled to certain benefits under this act. 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 states of reconstruction of the breast on which the mastectomy was performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
Continued on Page 8
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May 1, 2015 to April 30, 2016
Continued from Page 7
•
•
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 on
WHCRA benefits, call your plan administrator.
Medical Child Support Orders
An individual who is a child of a covered employee shall be enrolled for coverage under the group
health plan in accordance with the direction of a Qualified Medical Child Support Order (QMCSO)
or a National Medical Support Notice (NMSO).
A QMCSO is a state-court order or judgment, including approval of a settlement agreement that:
Provides for support of a covered employee’s child;
Provides for health care coverage for that child;
Is made under state domestic relations law (including a community property law);
Relates to benefits under the group health plan; and
Is “qualified” i.e., it meets the technical requirements of ERISA or applicable state law.
•
•
•
•
•
QMCSO also means a state court order or judgment enforcing state Medicaid law regarding medical
child support required by the Social Security Act § 1908 (as added by Omnibus Budget
Reconciliation Act of 1993).
An NMSO is a notice issued by an appropriate agency of a state or local government that is similar
to a QMCSO requiring coverage under the group health plan for a dependent child of a
non-custodial parent who is (or will become) a covered person by a domestic relations order
providing for health care coverage. Procedures for determining the qualified status of medical child
support orders are available at no cost upon request from the plan administrator.
Your Rights Under USERRA
A. Uniformed Services Employment and Reemployment Rights Act
USERRA protects the job rights of individuals who voluntarily or involuntarily leave employment
positions to undertake military service or certain types of service in the National Disaster Medical
System. USERRA also prohibits employers from discriminating against past and present members
of the uniformed services, and applicants to the uniformed services.
B. Reemployment Rights
You have the right to be reemployed in your civilian job if you leave that job to perform service in
the uniformed service and:
• You ensure that your employer receives advance written or verbal notice of your service;
• You have five years or less of cumulative service in the uniformed services while with that
particular employer;
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May 1, 2015 to April 30, 2016
Continued from Page 8
•
•
You return to work or apply for reemployment in a timely manner after conclusion of service;
and
You have not been separated from service with a disqualifying discharge or under other than
honorable conditions.
If you are eligible to be reemployed, you must be restored to the job and benefits you would have
attained if you had not been absent due to military service or, in some cases, a comparable job.
C. Right To Be Free From Discrimination and Retaliation
If you:
Are a past or present member of the uniformed service;
Have applied for membership in the uniformed service; or
Are obligated to serve in the uniformed service;
Then an employer may not deny you:
• Initial employment;
• Reemployment;
• Retention in employment;
• Promotion; or
• Any benefit of employment because of this status.
•
•
•
In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA
rights, including testifying or making a statement in connection with a proceeding under USERRA,
even if that person has no service connection.
D. Health Insurance Protection
•
•
If you leave your job to perform military service, you have the right to elect to continue your
existing employer-based health plan coverage for you and your dependents for up to 24 months
while in the military.
Even if you do not elect to continue coverage during your military service, you have the right to
be reinstated in your employer’s health plan when you are reemployed, generally without any
waiting periods or exclusions (e.g., preexisting condition exclusions) except for serviceconnected illness or injuries.
E. Enforcement
•
•
•
The U.S. Department of Labor, Veterans’ Employment and Training Service (VETS) is
authorized to investigate and resolve complaints of USERRA violations. For assistance in filing
a complaint, or for any other information on USERRA, contact VETS at 1-866-4-USA-DOL or
visit its website at http://www.dol.gov/vets. An interactive online USERRA Advisor can be
viewed at http://www.dol.gov/elaws/userra.htm.
If you file a complaint with VETS and VETS is unable to resolve it, you may request that your
case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for
representation.
You may also bypass the VETS process and bring a civil action against an employer for
violations of USERRA.
The rights listed here may vary depending on the circumstances.
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May 1, 2015 to April 30, 2016
Notice of HIPAA Special Enrollment Rights and
Preexisting Condition Exclusions
A federal law called HIPAA requires that you are notified about two very important provisions in
the medical plan. The first is your right to enroll in the plan under its “special enrollment provision”
if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible
dependent while other coverage is in effect and later lose that other coverage for certain qualifying
reasons. Second, this notice advises you of the plan's preexisting condition exclusion rules.
I. Special Enrollment Provision
Loss of Other Coverage (Excluding Medicaid or a State Children's Health Insurance
Program). If you decline enrollment for yourself or for an eligible dependent (including your
spouse) while other health insurance or group health plan coverage is in effect, 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 your or your dependents'
other coverage ends (or after the employer stops contributing toward the other coverage).
Loss of Coverage for Medicaid or a State Children's Health Insurance Program. If you decline
enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid
coverage or coverage under a state children's health insurance program is in effect, you may be able
to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that
other coverage. However, you must request enrollment within 60 days after your or your
dependents' coverage ends under Medicaid or a state children's health insurance program.
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. 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 new dependents. However, you must request enrollment within 30 days
after the marriage, birth, adoption, or placement for adoption.
Eligibility for Medicaid or a State Children's Health Insurance Program. If you or your
dependents (including your spouse) become eligible for a State premium assistance subsidy from
Medicaid or through a State children's health insurance program with respect to coverage under this
plan, you may be able to enroll yourself and your dependents in this plan. However, you must
request enrollment within 60 days after your or your dependents' determination of eligibility for
such assistance.
II. Preexisting Condition Exclusion Rules
This plan does not impose a preexisting condition exclusion.
If you terminate employment on or before December 31, 2014 and your new employer requires a
Certificate of Creditable Coverage, contact Dan Williams Company.
To obtain more information, contact:
Human Resources Department
Dan Williams Company
9050 N. Capital of Texas Hwy., #380
Austin, TX 78759
Telephone: (512) 320-1410
Dan Williams Company
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May 1, 2015 to April 30, 2016
** Continuation of Coverage Rights Under COBRA **
General Notice
Applicable to Employers with 20 or more Employees In the Previous Year
Introduction
You are receiving this notice because you may have recently become covered 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
generally explains COBRA continuation coverage, when it may become available to you and
your family, and what you need to do to protect your 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 when you would otherwise lose your group health coverage. It can also become available to
other members of your family who are covered under the Plan when they would otherwise lose their
group health coverage. For additional 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 coverage 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 either one of the following qualifying events occurs:
Your hours of employment are reduced, or
Your employment ends for any reason other than your gross misconduct.
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May 1, 2015 to April 30, 2016
Continued from Page 11
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your
coverage under the Plan because one of the following qualifying events occurs:
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 (enrolled in) 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 one of the following qualifying events occurs:
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 (enrolled in) 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 coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan has
been notified that a qualifying event has occurred. The employer must notify the Plan of the
following qualifying events:
End of employment or reduction of hours of employment;
Death of the employee.
You Must Give Notice of Some Qualifying Events
You must notify the Plan Administrator within sixty (60) days after any of the following
qualifying events occurs:
Divorce or legal separation;
Dependent child loses eligibility for coverage as a dependent child; or
The employee’s becoming entitled to (enrolled in) Medicare benefits (under Part A, Part B,
or both).
You must provide this notice to:
Human Resources Department
Dan Williams Company
9050 N. Capital of Texas Hwy., #380
Austin, TX 78759
Telephone: (512) 320-1410
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May 1, 2015 to April 30, 2016
Continued from Page 12
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 ways in which the 18-month period of COBRA continuation coverage can be extended:
Disability Extension of 18-month Period of COBRA 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 18month period of COBRA continuation coverage.
You must make sure that the Plan Administrator is notified of the Social Security Administration’s
determination within sixty (60) days of the date of the determination and before the end of the
eighteen (18) month period of COBRA continuation coverage. The affected individual must also
notify the Plan Administrator within thirty (30) days of any final determination that the individual is
no longer disabled.
Second Qualifying Event extension of 18-month period of COBRA continuation coverage
If your family experiences another qualifying event while receiving the 18 months of COBRA
continuation coverage, the spouse and dependent children in your family can receive up to 18
additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the
second qualifying event is properly given to the Plan Administrator. This extension may be
available to the spouse and any dependent children receiving COBRA continuation coverage if the
employee or former employee dies; becomes entitled to (enrolled in) 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.
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May 1, 2015 to April 30, 2016
Continued from Page 13
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 Administrator informed of address changes
To protect your family’s rights, you should 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
Human Resources Department
Dan Williams Company
9050 N. Capital of Texas Hwy., #380
Austin, TX 78759
Telephone: (512) 320-1410
If your employer has less than 20 employees, COBRA continuation coverage is not available.
COBRA continuation coverage does not apply to Life Insurance, Accidental Death &
Dismemberment Insurance or Disability Insurance.
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May 1, 2015 to April 30, 2016
Continued from Page 14
Texas State Continuation of Group Health Coverage
After Maximum COBRA Period Ends
Texas law requires some group health plans to continue coverage for an additional six months after
your maximum COBRA coverage period ends. For Texas State Continuation to apply, your plan
must have been issued by an insurance company or HMO subject to Texas insurance laws and rules.
It does not apply to employer self-funded (ERISA) health care plans, which are exempt from state
insurance laws.
Texas State Continuation does not apply to Group Dental or Group Vision plans.
If you were eligible for
COBRA as a result of:
Employee’s termination
of employment or decrease of working hours
COBRA
coverage
may continue
for up to ....
Qualified Beneficiaries:
Primary plan member
(Employee) and/or
dependents
18 months
If you were eligible for
COBRA as a result of:
- Death of Employee,
- Divorce*,
- Loss of Dependent
Child status*
COBRA
coverage
may continue
for up to ....
Qualified Beneficiaries:
Spouse, Ex-Spouse* or
Dependent Child
36 months
Texas State Continuation after COBRA
coverage ends may
continue for up to ....
+ 6 months
Texas Continuation
after COBRA
coverage ends may
continue for up to ....
+ 6 months
For a Total
Continuation
Period of up
to ….
24 months
For a Total
Continuation
Period of ….
42 months
* The Qualified Beneficiary is responsible for notifying the Plan Administrator that the Beneficiary
wishes to continue group medical coverage if the Qualifying Event is due to:
Loss of Dependent Child Status
Divorce
You must notify the employer, in writing, no later than the 60th day after coverage was terminated.
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May 1, 2015 to April 30, 2016
EMPLOYEE RIGHTS AND RESPONSIBILITIES
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Basic Leave Entitlement
FMLA requires covered employers to provide up
to 12 weeks of unpaid, job-protected leave to
eligible employees for the following reasons:
• For incapacity due to pregnancy, prenatal
medical care or childbirth;
• To care for the employee’s child after birth,
or placement for adoption or foster care;
• To care for the employee’s spouse, son,
daughter or parent, who has a serious health
condition; or
• For a serious health condition that makes the
employee unable to perform the employee’s
job.
Upon return from FMLA leave, most employees
must be restored to their original or equivalent
positions with equivalent pay, benefits, and other
employment terms.
Military Family Leave Entitlements
Eligible employees whose spouse, son, daughter
or parent is on covered active duty or call to
covered active duty status may use their 12-week
leave entitlement to address certain qualifying
exigencies. Qualifying exigencies may include
attending certain military events, arranging for
alternative childcare, addressing certain financial
and legal arrangements, attending certain
counseling sessions and attending postdeployment reintegration briefings.
FMLA also includes a special leave entitlement
that permits eligible employees to take up to 26
weeks of leave to care for a covered
servicemember during a single 12-month period.
A covered servicemember is (1) a current
member of the Armed Forces, including a
member of the National Guard or Reserves, who
is undergoing medical treatment, recuperation or
therapy, is otherwise in outpatient status, or is
otherwise on the temporary disability retired list,
for a serious injury or illness*; or (2) a veteran
who was discharged or released under conditions
other than dishonorable at any time during the
five-year period prior to the first date the eligible
employee takes FMLA leave to care for the
covered veteran, and who is undergoing medical
treatment, recuperation, or therapy for a serious
injury or illness.*
Definition of a Serious Health Condition
A serious health condition is an illness, injury,
impairment, or physical or mental condition that
involves either an overnight stay in a medical
care facility, or continuing treatment by a health
care provider for a condition that either prevents
the employee from performing the functions of
the employee’s job, or prevents the qualified
family member from participating in school or
other daily activities.
Use of FMLA leave cannot result in the loss of
any employment benefit that accrued prior to the
start of an employee’s leave.
Eligibility Requirements
Employees are eligible if they have worked for a
covered employer for at least 12 months, have
1,250 hours of service in the previous 12
months*, and if at least 50 employees are
employed by the employer within 75 miles.
Subject to certain conditions, the continuing
treatment requirement may be met by a period of
incapacity of more than 3 consecutive calendar
days combined with at least two visits to a health
care provider or one visit and a regimen of
continuing treatment, or incapacity due to
pregnancy, or incapacity due to a chronic
condition. Other conditions may meet the
definition of continuing treatment.
Benefits and Protections
During FMLA leave, the employer must maintain
the employee’s health coverage under a “group
health plan” on the same terms as if the employee
had continued to work.
Dan Williams Company
Use of Leave
An employee does not need to use this leave
entitlement in one block. Leave can be taken
intermittently or on a reduced leave schedule
when medically necessary. Employees must
make reasonable efforts to schedule leave for
planned medical treatment so as not to unduly
disrupt the employer’s operations. Leave due to
qualifying exigencies may also be taken on an
intermittent basis.
*The FMLA definitions of “serious injury or illness” for current
servicemembers and veterans are distinct from the FMLA definition of
“serious health condition.”
*Special hours of service eligibility requirements apply to airline flight
crew employees.
16
Continued on Page 17
May 1, 2015 to April 30, 2016
Continued from Page 16
employees’ rights and responsibilities. If they are
not eligible, the employer must provide a reason
for the ineligibility.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may
require use of accrued paid leave while taking
FMLA leave. In order to use paid leave for
FMLA leave, employees must comply with the
employer’s normal paid leave policies.
Covered employers must inform employees if
leave will be designated as FMLA-protected and
the amount of leave counted against the
employee’s leave entitlement. If the employer
Employee Responsibilities
Employees must provide 30 days advance notice determines that the leave is not FMLA-protected,
of the need to take FMLA leave when the need is the employer must notify the employee.
foreseeable. When 30 days notice is not
Unlawful Acts by Employers
possible, the employee must provide notice as
FMLA makes it unlawful for any employer to:
soon as practicable and generally must comply
• Interfere with, restrain, or deny the exercise
with an employer’s normal call-in procedures.
of any right provided under FMLA; and
Employees must provide sufficient information
• Discharge or discriminate against any person
for the employer to determine if the leave may
for opposing any practice made unlawful by
qualify for FMLA protection and the anticipated
FMLA or for involvement in any proceeding
timing and duration of the leave. Sufficient
under or relating to FMLA.
information may include that the employee is
Enforcement
unable to perform job functions, the family
member is unable to perform daily activities, the An employee may file a complaint with the U.S.
Department of Labor or may bring a private
need for hospitalization or continuing treatment
lawsuit against an employer.
by a health care provider, or circumstances
supporting the need for military family leave.
FMLA does not affect any Federal or State law
Employees also must inform the employer if the prohibiting discrimination, or supersede any State
requested leave is for a reason for which FMLA or local law or collective bargaining agreement
leave was previously taken or certified.
which provides greater family or medical leave
Employees also may be required to provide a
rights.
certification and periodic recertification
FMLA section 109 (29 U.S.C. § 2619) requires
supporting the need for leave.
FMLA covered employers to post the text of
Employer Responsibilities
this notice. Regulation 29 C.F.R. § 825.300(a)
Covered employers must inform employees
may require additional disclosures.
requesting leave whether they are eligible under
FMLA. If they are, the notice must specify any
additional information required as well as the
For addional informaon:
1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627
WWW.WAGEHOUR.DOL.GOV
U.S. Department of Labor Wage and Hour Division
WHD Publica.on 1420 · Revised February 2013
Dan Williams Company
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May 1, 2015 to April 30, 2016
NOTICE OF PRIVACY PRACTICES
Dan Williams Company
Health and Welfare Benefit Plan
9050 N. Capital of Texas Hwy., #380
Austin, TX 78759
(512) 320-1410
See page 19 for more
information on these
rights and how to
exercise them
See page 20 for more
information on these
choices and how to
exercise them
See pages 20 & 21
for more information on
these uses and
disclosures
Continued on Page 19
Dan Williams Company
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May 1, 2015 to April 30, 2016
Continued from Page 18
Continued on Page 20
Dan Williams Company
19
May 1, 2015 to April 30, 2016
Continued from Page 19
Continued Page 21
Dan Williams Company
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May 1, 2015 to April 30, 2016
Continued from Page 20
Marketing means making a communication about a product or service that encourages recipients
of the communication to purchase or use the product or services.
Texas employers:
• We are allowed to disclose genetic information only (1) under certain limited circumstances
and/or (2) to specific recipients.
• We are allowed to disclose HIV/AIDS-related information only (1) under certain limited
circumstances and/or (2) to specific recipients.
• We are allowed to use and disclose child and/or adult abuse information only (1) under
certain limited circumstances and/or (2) to specific recipients.
Continued on Page 22
Dan Williams Company
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May 1, 2015 to April 30, 2016
Continued from Page 21
Our Responsibilities
•
•
•
•
We are required by law to maintain the privacy and security of your protected health
information.
We will let you know promptly if a breach occurs that may have compromised the
privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you
a copy of it.
We will not use or share your information other than as described here unless you tell
us we can in writing. If you tell us we can, you may change your mind at any time.
Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/
consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we
have about you. The new notice will be available upon request.
Effective Date of Notice: March 18, 2015
This Notice of Privacy Practices applies to the following organizations.
Dan Williams Company Health and Welfare Benefit Plan
Jennifer Hartman
E-Mail: [email protected]
(512) 320-1410
Dan Williams Company
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May 1, 2015 to April 30, 2016
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 January 31,
2014. Contact your state for more information on eligibility.
Continued on Page 24
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May 1, 2015 to April 30, 2016
Continued from Page 23
IOWA — Medicaid
ALABAMA — Medicaid
Website: http://www.medicaid.alabama.gov
Website: www.dhs.state.ia.us/hipp/
Phone: 1-855-692-5447
Phone: 1-888-346-9562
ALASKA — Medicaid
KANSAS — Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/
medicaid/
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA — CHIP
KENTUCKY — Medicaid
Website: http://www.azahcccs.gov/applicants
Website: http://chfs.ky.gov/dms/default.htm
Phone (Outside of Maricopa County): 1-877-764-5437
Phone (Maricopa County): 602-417-5437
Phone: 1-800-635-2570
COLORADO — Medicaid
LOUISIANA — Medicaid
Medicaid Website: http://www.colorado.gov/
Website: http://www.lahipp.dhh.louisiana.gov
Medicaid Phone (In state): 1-800-866-3513
Medicaid Phone (Out of state): 1-800-221-3943
Phone: 1-888-695-2447
FLORIDA — Medicaid
MAINE — Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
Phone: 1-877-357-3268
Phone: 1-800-977-6740
TTY 1-800-977-6741
GEORGIA — Medicaid
MASSACHUSETTS — Medicaid and CHIP
Website: http://dch.georgia.gov/ - Click on Programs, then
Medicaid, then Health Insurance Premium Payment (HIPP)
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
Phone: 1-800-869-1150
IDAHO — Medicaid
MINNESOTA — Medicaid
Medicaid Website: http://healthandwelfare.idaho.gov/
Medical/Medicaid/PremiumAssistance/tabid/1510/
Default.aspx
Website: http://www.dhs.state.mn.us/
Medicaid Phone: 1-800-926-2588
Phone: 1-800-657-3629
Click on Health Care, then Medical Assistance
INDIANA — Medicaid
MISSOURI — Medicaid
Website: http://www.in.gov/fssa
Website: http://www.dss.mo.gov/mhd/participants/
pages/hipp.htm
Phone: 1-800-889-9949
Phone: 573-751-2005
Continued on Page 25
Dan Williams Company
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May 1, 2015 to April 30, 2016
Continued from Page 24
MONTANA — Medicaid
OKLAHOMA — Medicaid and CHIP
Website: http://medicaidprovider.hhs.mt.gov/
clientpages/clientindex.shtml
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
Phone: 1-800-694-3084
NEBRASKA — Medicaid
OREGON — Medicaid
Website: www.ACCESSNebraska.ne.gov
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-699-9075
Phone: 1-800-383-4278
NEVADA — Medicaid
PENNSYLVANIA — Medicaid
Medicaid Website: http://dwss.nv.gov/
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
Medicaid Phone: 1-800-992-0900
NEW HAMPSHIRE — Medicaid
RHODE ISLAND — Medicaid
Website: www.ohhs.ri.gov
Website: http://www.dhhs.nh.gov/oii/documents/
hippapp.pdf
Phone: 401-462-5300
Phone: 603-271-5218
NEW JERSEY — Medicaid and CHIP
SOUTH CAROLINA — Medicaid
Medicaid Website: http://www.state.nj.us/
humanservices/dmahs/clients/medicaid/
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NEW YORK — Medicaid
SOUTH DAKOTA — Medicaid
Website: http://www.nyhealth.gov/health_care/
medicaid/
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Phone: 1-800-541-2831
NORTH CAROLINA — Medicaid
TEXAS — Medicaid
Website: http://www.ncdhhs.gov/dma
Website: https://www.gethipptexas.com/
Phone: 919-855-4100
Phone: 1-800-440-0493
NORTH DAKOTA — Medicaid
UTAH — Medicaid and CHIP
Website: http://www.nd.gov/dhs/services/medicalserv/
medicaid/
Website: http://health.utah.gov/upp
Phone: 1-866-435-7414
Phone: 1-800-755-2604
Continued on Page 26
Dan Williams Company
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May 1, 2015 to April 30, 2016
Continued from Page 25
WEST VIRGINIA — Medicaid
VERMONT — Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820,
HMS Third Party Liability
VIRGINIA — Medicaid and CHIP
WISCONSIN — Medicaid
Medicaid Website: http://www.dmas.virginia.gov/
rcp-HIPP.htm
Website: http://www.badgercareplus.org/pubs/p10095.htm
Medicaid Phone: 1-800-432-5924
Phone: 1-800-362-3002
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
WASHINGTON — Medicaid
WYOMING — Medicaid
Website: http://www.hca.wa.gov/medicaid/
premiumpymt/pages/index.aspx
Website: http://health.wyo.gov/healthcarefin/
equalitycare
Phone: 1-800-562-3022 ext. 15473
Phone: 307-777-7531
To see if any other states have added a premium assistance program since January 31, 2014, or for
more information on special enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
1-866-444-EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Menu Option 4, Ext. 61565
Dan Williams Company
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May 1, 2015 to April 30, 2016
Important Notice From Dan Williams Company 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 Dan Williams Company 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. Dan Williams Company has determined that the prescription drug coverage offered by the
Dan Williams Company Group Medical Plans 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 Prescription 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 after
that between October 15th and December 7th .
However, if you lose your current creditable prescription drug coverage, through no fault of your
own, you will 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 Dan Williams Company coverage will not
be affected. You can keep the current coverage, and this plan may coordinate with Medicare Part D
coverage.
Continued on Page 28
Dan Williams Company
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May 1, 2015 to April 30, 2016
Continued from page 27
Please Note: The medical and prescription drug benefits under the Dan Williams Company plan
are bundled. You cannot drop prescription drug coverage and maintain medical coverage on a
stand-alone basis.
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 Dan Williams
Company 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.
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 19 months without creditable prescription drug 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 for the Medicare Part D
Open Enrollment Period to join.
For more information about this notice or your current prescription drug coverage, contact
the person(s) listed below for further information.
Human Resources Department
Dan Williams Company
9050 N. Capital of Texas Hwy., #380
Austin, TX 78759
Telephone: (512) 320-1410
NOTE: You will receive this notice each year before the next Medicare Part D open enrollment
period during which you can join a Medicare drug plan.
You will also receive a similar notice if this Prescription Drug plan coverage through Dan
Williams Company changes.
You may request a copy of this notice at any time.
Continued on Page 29
Dan Williams Company
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May 1, 2015 to April 30, 2016
Continued from Page 28
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 after you are eligible for 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 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 enroll 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).
Date:
Name of Sender:
March 18, 2015
Dan Williams Company
Contact:
Human Resources Department
Address:
9050 N. Capital of Texas Hwy., #380
Austin, TX 78759
Telephone:
Dan Williams Company
(512) 320-1410
29
May 1, 2015 to April 30, 2016
Bowen, Miclette & Britt Insurance Agency, LLC., in accordance with HIPAA
Privacy Laws, is committed to safeguarding your Protected Health Information (PHI).
Therefore, when assisting with a claim dispute or questions we will only discuss your
Protected Health Information with medical providers and third party administrators
with your written consent.
Employees must complete an authorization form provided by us in order to
receive our assistance with claims issues.
An authorization form should only be signed when a representative of Bowen,
Miclette & Britt or the Dan Williams Company Benefits Administrator will be assisting you.
Prepared by:
Bowen, Miclette & Britt Insurance Agency, LLC.
These notices are furnished by Bowen, Miclette & Britt Insurance Agency, LLC .
They are based on Model Notices furnished by the Federal Government for Regulations in
effect on January 22, 2015. However, these regulations can change at any time.
These notices are not intended to be a substitute for certain notices, workplace
posters and other communications that the law requires employers to provide to employees.
For example, employers that self-administer their COBRA obligations are advised to
provide the Initial Notice and Qualifying Event Notice to employees at their home address
in a timely manner.
Additionally, all employers are advised to display the appropriate posters in the
workplace.
If there are any questions, please contact your Human Resources administrator or
the Bowen, Miclette & Britt Account Manager for assistance.
Dan Williams Company
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May 1, 2015 to April 30, 2016