The State of Texas requires notices to be given to

insureds and applicants regarding coverage for

certain mandated benefits. These rules originally

became effective on March 29, 1998, but were

periodically revised as new mandates were added.

The last revision was on January 19, 2006 with the

addition of the human papillomavirus and cervical

cancer screening mandate.

The following are notices to advise you of

certain coverage and/or benefits provided by

your contract with your carrier.

Mastectomy or Lymph Node Dissection

Minimum Inpatient Stay: If due to treatment of

breast cancer, any person covered by this plan

has either a mastectomy or a lymph node

dissection, this plan will provide coverage for

inpatient care for a minimum of:

(a) 48 hours following a mastectomy, and

(b) 24 hours following a lymph node dissection.

The minimum number of inpatient hours is

not required if the covered person receiving

the treatment and the attending physician

determine that a shorter period of inpatient

care is appropriate.

Prohibitions: we may not (a) deny any covered

person eligibility or continued eligibility or fail to

renew this plan solely to avoid providing the

minimum inpatient hours; (b) provide money

payment or rebates to encourage any covered

person to accept less than the minimum inpatient

hours; (c) reduce or limit the amount paid to the

attending physician, because the physician

required a covered person to receive the minimum

inpatient hours; or (d) provide financial or other

incentives to the attending physician to encourage

the physician to provide care that is less than the

minimum hours.

Coverage of Test for Detection of Human

Papillomavirus and Cervical Cancer

Coverage is provided, for each woman enrolled

on the plan who is 18 years of ago or older, for

expenses incurred for an annual medically

recognized diagnostic examination for the early

detection of cervical cancer.

Coverage required under this section includes at

a minimum a conventional Pap smear screening

or a screening using liquid-based cytology

methods, as approved by the United States Food

and Drug Administration, alone or in

combination with a

test approved by the United States Food and Drug

Administration for the detection of the human

papillomavirus.

Coverage and/or Benefits for Reconstructive

Surgery After Mastectomy-Enrollment

Coverage and/or benefits are provided to each

covered person for reconstructive surgery after

mastectomy, including:

(a) all stages of the reconstruction of the

breast on which mastectomy has been

preformed; (b) surgery and reconstruction of

the other breast to achieve a symmetrical

appearance; and

(c) prostheses and treatment of physical

complications, including lymphedemas, at all

stages of mastectomy.

The coverage and/or benefits must be

provided in a manner determined to be

appropriate in consultation with the covered

person and the attending physician.

Deductible, copayments, and/or coinsurance is

applicable to coverage and/or benefits, as shown in

Schedule of Benefits.

Prohibitions: we may not (a) offer the covered

person a financial incentive to forego breast

reconstruction or waive the coverage and/or

benefits shown above; (b) condition, limit, or deny

any covered person’s eligibility or continued

eligibility to enroll in the plan or fail to renew this

plan solely to avoid providing the coverage and/or

benefits shown above; or (c) reduce or limit the

amount paid to the physician or provider, nor

otherwise penalize, or provide a financial incentive

to induce the physician or provider to provide care

to a covered person in a manner inconsistent with

the coverage and/or benefits shown above.

Coverage and/or Benefits for Reconstructive

Surgery After Mastectomy-Annual

Your Contract, as requires by the federal

Women’s Health and Cancer Rights Act of

Texas Notice of Mandatory Benefits

1998, provides benefits for mastectomy-

related services including reconstruction and

surgery to achieve symmetry between the

breasts, prostheses, and complications

resulting from a mastectomy (including

lymphedema).

Examination for Detection of Prostate Cancer

Benefits are provided for each covered male

for an annual medically recognized

diagnostic examination for the detection of

prostate cancer. Benefits include:

(a) a physical examination for the detection of

prostate cancer; and

(b) a prostate-specific antigen test for each covered

male who is

(1) at least 50 years of age; or

(2) at least 40 years of age with a family history

of prostate cancer or other prostate cancer risk

factor.

Inpatient Stay following Birth of a Child

For each person covered for maternity/childbirth

benefits, we will provide inpatient care for the

mother and her newborn child in a health care

facility for a minimum of:

(a) 48 hours following an uncomplicated vaginal

delivery; and

(b) 96 hours following an uncomplicated delivery

by cesarean section.

This benefit does not require a covered female

who is eligible for maternity/childbirth benefits to

(a) give birth in a hospital or other health care

facility or (b) remain in a hospital or other heath

care facility for the minimum number of hours

following birth of the child.

If a covered mother or her newborn child is

discharges before the 48 or 96 hours has expired,

we will provide coverage for post delivery care.

Post delivery care includes parent education,

assistance and training in breast-feeding and

bottle-feeding and the performance of any

necessary and appropriate clinical tests. Care will

be provided by a physician, registered nurse or

other appropriate licensed health care provider,

and the mother will have the option of receiving

the care at her home, the health care provider’s

office or a health care facility.

If a decision is made to discharge the woman prior

to the expiration of the minimum hours of

coverage, in-home post-partum care provide by a

Physician, registered nurse or other appropriate

provider will be covered.

Post-partum care includes health care services in

accordance with accepted maternal and new-

natal physical assessments, including: parent

education, assistance and training in breast-

feeding and bottle-feeding, and the performance

of any necessary clinical tests.

Prohibitions: we may not (a) modify the terms of

this coverage based on any covered person

requesting less than the minimum coverage

required; (b) offer the mother financial incentives

or other compensation for waiver of the minimum

number of hours required; (c) refuse to accepts a

physician’s recommendation for a specified

period of inpatient care made in consultation with

the mother if the period recommended by the

physician does not exceed guidelines for prenatal

care developed by nationally recognized

professional associations of obstetricians and

gynecologists or pediatricians; (d) reduce

payments or reimbursements below the usual and

customary rate; or (f) penalize a physician for

recommending inpatient care for the mother and/or

newborn child.

Coverage for Tests for Detection of Colorectal

Cancer

Benefits are provided, for each person enrolled in

the plan who is 50 years of age or older and at

normal risk for developing colon cancer, for

expenses incurred in conducting a medically

recognized screening examination for the

detection of colorectal cancer. Benefits include

the covered person’s choice of:

(a) a fecal occult blood test performed

annually and a flexible

sigmoidoscopy performed every

five years, or

(b) a colonoscopy performed every 10 years.

New Genetic Nondiscrimination Law Applies to

Employers and Health Insurers

The Genetic Information Nondiscrimination Act

of 2008 (GINA), signed by President Bush on

May 21, amends several statutes regarding

employment and health insurance, including Title

VII of the Civil Rights Act of 1964 (Title VII),

the Employee Retirement Income Security Act of

1974 (ERISA) and the Internal Revenue Code of

1986 (Code). GINA's stated intent is "to prohibit

discrimination on the basis of genetic information

with respect to health insurance and

employment." Sections of the law related to

health insurance will take effect for plan years

beginning after May 2009 (January 1, 2010 for

calendar year plans). Employment-related

changes will take effect in November 2009.

According to GINA's supporters, many

Americans have declined genetic testing and

services for fear that information about genetic

findings could affect their health insurance and

employment. GINA is designed to relieve these

fears by protecting the public from

discrimination based on genetic information.

GINA is, however, unique in the history of

nondiscrimination law, in that it was written

primarily to be proactive, rather than as a

reaction to pervasive discrimination. Without

such a history of past discrimination, it is

particularly difficult to predict GINA's impact

either on health insurance or employment.

Genetic Information

GINA broadly defines "genetic information" to

include the results from or information about

"genetic tests" or "genetic services" for an

individual or "family member" and the

manifestation of a disease or disorder in a

"family member." Genetic information does not,

however, include an individual's age or sex.

"Genetic tests" generally include analysis of

DNA and chromosomes to detect genotypes,

mutations or chromosomal changes. (See

"GINA Questions and Answers" for examples.)

Covered "family members" include fourth-

degree relatives, such as great-great-

grandparents and their descendants.

GINA also protects the genetic information of

fetuses and embryos. For example, a health

care plan must not discriminate against a

pregnant woman's fetus that has been

genetically tested for Down syndrome on the

basis of the genetic test.

Amendments to Title VII

GINA amends Title VII to prohibit employers,

among others, from discrimination in the terms

and conditions of employment based on genetic

information. The rights, procedures and remedies

for GINA are the same as for Title VII. GINA

does not allow a cause of action based on

disparate impact, but GINA contemplates that

such a cause of action could exist. The statute

establishes a commission—beginning six years

from enactment of GINA—to study

developments in genetic

technology and consider the application of the

disparate impact theory to genetic information.

Employers must not fail to hire, discharge or

classify employees on the basis of genetic

information, and must not request, require or

purchase genetic information, unless an

exception applies. (See "GINA Questions and

Answers" for a discussion of exceptions.)

Finally, employers must not retaliate against an

individual based on the exercise of rights created

by GINA.

Genetic information, whether lawfully or

inadvertently collected by employers, must be

kept in a separate file from the employee's

personnel file. Employers must not disclose

employees' genetic information, unless an

exception applies. (See "GINA Questions and

Answers" for a discussion of exceptions.)

Amendments to ERISA and Other Statutes

GINA amends ERISA and the Code to impose

penalties and taxes for discrimination in health

insurance on the basis of genetic information.

Group health plans, among others, must not

request or require genetic information for

underwriting or enrollment purposes, unless an

exception applies. (See "GINA Questions and

Answers" for a discussion of exceptions.) GINA

also prohibits health insurers from increasing

premiums on a group basis based on genetic

information.

GINA required the U.S. Department of

Health and Human Services to issue

final regulations to include "genetic

information" in the definition of "private

health information."

While GINA itself does not impose

any notice obligations on health

insurers or employers, future

regulations may create such

obligations.

Regulations

GINA requires that regulations be published by

May 21, 2009. Many issues are left to be

addressed in these regulations, including:

Whether a disease or disorder of

family members has to be a genetic

disease or disorder—and specific

examples of genetic tests;

If the "bona fide occupational

qualification" defense, which may

be used by employers in defense

of some other cases under Title

VII, may be used by employers in

cases of genetic discrimination;

Whether there is any exception to GINA

for employers requesting information for

non-FMLA leaves such as paid leaves of

IMPORTANTANT LEGISLATIVE

CHANGES HIPAA NOTICE

absence or bereavement leaves, or for

providing reasonable accommodations

required under the Americans with

Disabilities Act; and

How the maximum penalty for health

insurers will be calculated.

Regulations addressing those and many other

issues will to a large extent determine GINA's

ultimate impact. The agencies responsible for the

GINA health insurance regulations have

requested comments from the general public

regarding health insurance issues under GINA.

These comments are due by December 9, 2008.

In 1996 Congress passed the Health Insurance

Portability and Accountability Act of 1996

(HIPAA). HIPAA impacts group health plans by

improving the availability and

portability of health coverage. HIPAA also

requires that group health plan participants be

given the following notices.

Notice of Enrollment Rights –

If you are declining enrollment

for yourself or your dependents

(including your spouse) because

of other health insurance

coverage, you may in the future

be able to enroll yourself or your

dependents in this plan,

provided that you request

enrollment within 30 days after

your other coverage ends. In

addition, if you have a new

dependent as a result of

marriage, birth, adoption, or

placement of adoption, you may

be able to enroll yourself and

your dependents, provided that

you request enrollment within

30 days after the marriage, birth,

adoption, or placement of

adoption.

Notice of Pre-existing

Condition Exclusion -

Under HIPAA, a ―pre-

existing condition‖ is a

condition for which medical

advice, diagnosis, care, or

treatment was

recommended or received

within the six month period

ending on the enrollment

date in a health plan.

Your plan may exclude a pre-

existing condition. If so, the

pre-existing condition

exclusion waiting period will

not exceed 12 months

beginning on the enrollment

date. (For a late enrollee, the

maximum waiting period is 18

months from the date coverage

begins). A pre-existing

condition exclusion is

inapplicable to a pregnancy or

to a newborn child or adopted

child under age 18 who

becomes covered within 30

days of birth or adoption. A

genetic condition without

advice, care, or treatment is not

a pre-existing condition.

If your plan contains a pre-

existing condition exclusion, the

existence of a pre-existing

condition will be determined

using information obtained

relating to an individual’s health

status before his or her

enrollment date.

The pre-existing condition

waiting period is reduced by any

creditable coverage (prior

coverage under various plans

including, but not limited to,

group health plans, individual

health policies, Medicare, and

Medicaid). You may obtain a

certificate of creditable coverage

from a prior plan sponsor or

health insurance issuer. Should

you disagree with the length of

creditable coverage determined

by your current plan, you have

the right to appeal that

determination and provide

evidence of creditable coverage.

You should read and consult

your schedule of benefits to see if

your health plan contains a pre-

existing condition exclusion.

For further information, contact your benefits

administrator.

NOTICE

CONTINUATION COVERAGE RIGHTS UNDER COBRA

Note: Certain employers may not be affected by

Continuation of Coverage after termination (COBRA).

See your employer or Group Administrator should you

have any questions about COBRA.

INTRODUCTION

You are receiving this notice because you have recently

become covered under your employer’s 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 the right to receive it.

The right to COBRA continuation coverage was created by a

federal law, the Consolidated Omnibus Budget Reconciliation

Act of 1985 (COBRA). COBRA continuation coverage may

be available to you when you would otherwise lose your group

health coverage. It can also become available to other

member of your family who are coverage 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.

WHAT IS COBRA CONTINUATION COVERAGE?

COBRA continuation coverage is a continuation of Plan

coverage when coverage would otherwise end because of a

life event know 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 of you lose your coverage under the Plan because

either one of the following qualifying events happens:

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 any of the following qualifying events happens:

Your spouse dies;

Your spouse’s hours of employment ends are reduced;

Your spouse’s employment ends for any reason other than

his or her gross misconduct;

Your spouse becomes 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 will lose coverage under the Plan because any of the

following qualifying events happens:

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 enrolled in Medicare (Part

A, Part B, or both);

The parent becomes divorced or legally separated; or

The child stops being eligible for coverage under then Plan

as a ―dependent child.‖

If the plan provides health care coverage to retired employees,

the following applies: Sometimes, filing a proceeding in

bankruptcy under title 11 of the United States Code can be a

qualifying event. If a proceeding in bankruptcy is filed with

respect to your employer, and that bankruptcy results in the

loss of coverage of any retired employee under the Plan, the

retired employee will become a qualified beneficiary with

respect to bankruptcy. The retired employee’s spouse,

surviving spouse, and dependent children will also become

qualified beneficiaries of bankruptcy results in the loss of their

coverage under than Plan.

WHEN IS COBRA 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. When the

qualifying event is the end of employment or reduction in

hours of employment, death of the employee, in the event of

retired employee health coverage, commencement of a

proceeding in bankruptcy with respect to the employer, or the

employee’s becoming entitles to Medicare benefits (under Part

A, Part B, or both), the employer must notify the Plan

Administrator of the qualifying event.

CONT’D NOTICE

CONTINUATION COVERAGE RIGHTS UNDER COBRA

YOU MUST GIVE NOTICE OF SOME QUALIFYING

EVENTS

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 60 days after the qualifying

event occurs. Contact your employer and/or COBRA

Administrator for procedures for this notice, including a

description of any required information or documentation.

HOW IS COBRA COVERAGE PROVIDED?

Once the Plan Administrator received 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 temporary continuation of

coverage. when the qualifying event is the death of the

employee, the employee’s becoming entitled to Medicare

benefits (under Part A, Part B, or both), your divorce or legal

separation, or a dependent child’s losing eligibility as a

dependent child, COBRA continuation coverage lasts for up to

36 months.

When the qualifying event is the end of employment or

reduction of the employee’s hours of employment became

entitle to Medicare benefits less than 18 months before the

qualifying event, COBRA continuation coverage for qualified

beneficiaries other than the employee lasts until 36 months

after the date of Medicare entitlement. For example, if a

covered employee becomes entitled to Medicare 8 months

before date on which his employment terminates, COBRA

continuation coverage for his spouse and children can last up

to 36 months after the date of the qualifying event (36 months

minus 8 months). Otherwise, when the qualifying event is the

end of employment or reduction of the employee’s hour of

employment, COBRA continuation coverage generally lasts

for only up to a total of 18 months. There are two ways in

which this 18-moth 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 mo nths of COBRA continuation

coverage, for a total maximum of 20 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. Contact

your employer and/or the COBRA Administrator for

procedures for this notice, including a description of any

required information or documentation.

SECOND QUALIFYING EVENT EXTENSION OF 18-

MONTH PERIOD OF CONTINUATION COVERAGE If your family experiences another qualifying event while

receiving 18 months 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 notice of the second qualifying

event is properly given to the Plan. This extension may be

available to the spouse and dependent children receiving

continuation coverage if the employee or former employee

dies, becomes entitled to Medicare benefits (under Part A, Part

B, or both), or gets divorced or legally separated or of the

dependent child stops being eligible under the Plan as a

dependent child, but only if the event would have caused the

spouse or dependent child to lose coverage under the Plan has

the first qualifying event not occurred.

IF YOU HAVE QUESTIONS

Questions concerning your Plan or your COBRA continuation

coverage rights, should be addressed to your Plan

Administrator. For more information about your rights under

ERISA, including COBRA, the Health Insurance Portability

and Accountability Act (HIPAA), and other laws affecting

group health plan, contact the Labor’s 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/esba . (Addresses and phone

numbers of Regional and District EBSA Offices are available

through EBSA’s website.)

KEEP YOUR PLAN INFORMED OF ADDRESS

CHANGES

In order to protect your family’s rights, you should keep the

Plan Administrator informed of 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

Contact your employer for the name, address and telephone

number of the party responsible for administering your

COBRA continuation coverage.

7

Medicaid and the Children’s Health Insurance Program (CHIP)

Offer Free Or Low-Cost Health Coverage To Children And Families

If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have

premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP

programs to help people who are eligible for employer- sponsored health coverage, but need assistance in paying their

health premiums.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can

contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your

dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-

877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a

program that might help you pay the

premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your

employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your

dependents are eligible, but not already enrolled in the employer’s plan. This is called a ―special enrollment‖

opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.

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 March 3, 2010. You should contact your State for

further information on eligibility –

ALABAMA – Medicaid CALIFORNIA – Medicaid

Website: http://www.medicaid.alabama.gov

Phone: 1-800-362-1504

Website: http://www.dhcs.ca.gov/services/Pages/

TPLRD_CAU_cont.aspx

Phone: 1-866-298-8443

ALASKA – Medicaid COLORADO – Medicaid and CHIP

Website: http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890

Phone (Anchorage): 907-269-6529

Medicaid Website: http://www.colorado.gov/

Medicaid Phone: 1-800-866-3513

CHIP Website: http:// www.CHPplus.org

CHIP Phone: 303-866-3243 ARIZONA – CHIP

Website: http://www.azahcccs.gov/applicants/default.aspx

Phone: 602-417-5422

ARKANSAS – CHIP FLORIDA – Medicaid

Website: http://www.arkidsfirst.com/

Phone: 1-888-474-8275

Website: http://www.fdhc.state.fl.us/Medicaid/index.shtml

Phone: 1-866-762-2237

GEORGIA – Medicaid MONTANA – Medicaid

Website: http://dch.georgia.gov/

Click on Programs, then Medicaid

Phone: 1-800-869-1150

Website: http://medicaidprovider.hhs.mt.gov/clientpages/

clientindex.shtml

Telephone: 1-800-694-3084

IDAHO – Medicaid and CHIP NEBRASKA – Medicaid

8

Medicaid Website: www.accesstohealthinsurance.idaho.gov

Medicaid Phone: 208-334-5747

CHIP Website: www.medicaid.idaho.gov

CHIP Phone: 1-800-926-2588

Website: http://www.dhhs.ne.gov/med/medindex.htm

Phone: 1-877-255-3092

INDIANA – Medicaid NEVADA – Medicaid and CHIP

Website: http://www.in.gov/fssa/2408.htm

Phone: 1-877-438-4479

Medicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900

CHIP Website: http://www.nevadacheckup.nv.org/

CHIP Phone: 1-877-543-7669

IOWA – Medicaid

Website: www.dhs.state.ia.us/hipp/

Phone: 1-888-346-9562

KANSAS – Medicaid NEW HAMPSHIRE – Medicaid

Website: https://www.khpa.ks.gov

Phone: 800-766-9012

Website: http://www.dhhs.state.nh.us/DHHS/

MEDICAIDPROGRAM/default.htm

Phone: 1-800-852-3345 x 5254

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: 1-800-356-1561

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid

Website: www.dhh.louisiana.gov/offices/?ID=92

Phone: 1-888-342-6207

MAINE – Medicaid NEW MEXICO – Medicaid and CHIP

Website: http://www.maine.gov/dhhs/oms/

Phone: 1-800-321-5557

Medicaid Website:

http://www.hsd.state.nm.us/mad/index.html

Medicaid Phone: 1-888-997-2583

CHIP Website:

http://www.hsd.state.nm.us/mad/index.html

Click on Insure New Mexico

CHIP Phone: 1-888-997-2583

MASSACHUSETTS – Medicaid and CHIP

Medicaid & CHIP Website:

http://www.mass.gov/MassHealth

Medicaid & CHIP Phone: 1-800-462-1120

MINNESOTA – Medicaid NEW YORK – Medicaid

Website: http://www.dhs.state.mn.us/

Click on Health Care, then Medical Assistance

Phone: 800-657-3739

Website: http://www.nyhealth.gov/health_care/

medicaid/

Phone: 1-800-541-2831

MISSOURI – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.dss.mo.gov/mhd/index.htm

Phone: 573-751-6944

Website: http://www.nc.gov

Phone: 919-855-4100

NORTH DAKOTA – Medicaid UTAH – Medicaid

Website:

http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-800-755-2604

Website: http://health.utah.gov/medicaid/

Phone: 1-866-435-7414

9

OKLAHOMA – Medicaid VERMONT– Medicaid

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

Website: http://ovha.vermont.gov/

Telephone: 1-800-250-8427

OREGON – Medicaid and CHIP VIRGINIA – Medicaid and CHIP

Medicaid Website:

http://www.oregon.gov/DHS/healthplan/index.shtml

Medicaid Phone: 1-800-359-9517

CHIP Website:

http://www.oregon.gov/DHS/healthplan/app_benefits/

ohp4u.shtml

CHIP Phone: 1-800-359-9517

Medicaid Website: http://www.dmas.virginia.gov/rcp-

HIPP.htm

Medicaid Phone: 1-800-432-5924

CHIP Website: http://www.famis.org/

CHIP Phone: 1-866-873-2647

PENNSYLVANIA – Medicaid WASHINGTON – Medicaid

Website:

http://www.dpw.state.pa.us/partnersproviders/medicalassista

nce/doingbusiness/003670053.htm

Phone: 1-800-644-7730

Website:

http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm

Phone: 1-877-543-7669

RHODE ISLAND – Medicaid WEST VIRGINIA – Medicaid

Website: www.dhs.ri.gov

Phone: 401-462-5300

Website: http://www.wvrecovery.com/hipp.htm

Phone: 304-342-1604

SOUTH CAROLINA – Medicaid WISCONSIN – Medicaid

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820

Website: http://dhs.wisconsin.gov/medicaid/publications/p-

10095.htm

Phone: 1-800-362-3002

TEXAS – Medicaid WYOMING – Medicaid

Website: https://www.gethipptexas.com/

Phone: 1-800-440-0493

Website:

http://www.health.wyo.gov/healthcarefin/index.html

Telephone: 307-777-7531

To see if any more States have added a premium assistance program since March 3, 2010, or for more information

on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human Services

Employee Benefits Security Administration Centers for Medicare & Medicaid Services

www.dol.gov/ebsa www.cms.hhs.gov

1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565

OMB Control Number 1210-0137 (expires 07/31/2010)

NOTICE

LIFETIME LIMIT NO LONGER APPLIES AND ENROLLMENT

OPPORTUNITY

The lifetime limit on the dollar value of benefits under

your health plan no longer applies. Individuals whose

coverage ended by reason of reaching lifetime limit under

the plan are eligible to enroll in the plan. Individuals have

30 days from the date of this notice to request enrollment.

For more information contact your Plan Administrator. PATIENT PROTECTION DISCLOSURE

Your Plan generally requires/allows the

designation of a primary care provider. You

have the right to designate any primary care

provider who participates in our network and

who is available to accept you or your family

members. If your plan or health insurance

coverage designates a primary care provider

automatically, until you make this designation,

your Plan designates one for you. For

information on how to select a primary care

provider, and for a list of the participating

primary care providers, contact the Plan

Administrator at (512) 478-9595.

For children, you may designate a pediatrician as

the primary care provider.

If your plan provides coverage for obstetric or

gynecological care and requires the designation

by a participant or beneficiary of a primary care

provider:

You do not need prior authorization from your

Plan or from any other person (including a

primary care provider) in order to obtain access

to obstetrical or gynecological care from a health

care professional in our 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, contact the Plan Administrator at

(512) 478-9595.

Notice of Opportunity to Enroll In

Connection with Extension of

Dependent Coverage to Age 26

Individuals whose coverage ended, or who were denied

coverage (or were not eligible for coverage), because the

availability of dependent coverage of children ended

before attainment of age 26 are eligible to enroll in your

Group Health Insurance Plan. Individuals may request

enrollment for such children for 30 days from the date of

notice. Enrollment will be effective retroactively to the

date that is the first day of the first plan year beginning

on or after September 23, 2010. For more information

contact the Plan Administrator at (512) 478-9595.

NOTICE OF PRIVCAY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL

INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET

ACCESS TO THIS INFORMATION. PLEASE

REVIEW IT CAREFULLY.

Our Company’s Pledge to You

This notice is intended to inform you of the privacy

practices followed by your contract with your carrier (the

Plan) and the Plan’s legal obligations regarding your

protected health information under the Health Insurance

Portability and Accountability Act of 1996 (HIPAA). The

notice also explains the privacy rights you and your

family members have as participants of the Plan.

The Plan Administrator often needs access to your

protected health information in order to provide

payment for health services and perform plan

administrative functions. We want to assure the plan

participants covered under the Plan that we comply

with federal privacy laws and respect your right to

privacy. It is required that all members of our

workforce and third parties that are provided access to

protected health information comply with the privacy

practices outlined below.

Protected Health Information

Your protected health information is protected by the

HIPAA Privacy Rule. Generally, protected health

information is information that identifies an individual

created or received by a health care provider, health

plan or an employer on behalf of a group health plan

that relates to physical or mental health conditions,

provision of health care, or payment for health care,

whether past, present or future.

How We May Use Your Protected Health Information

Under the HIPAA Privacy Rule, we may use or

disclose your protected health information for

certain purposes without your permission. This

section describes the ways we can use and disclose

your protected health information.

Payment. We use or disclose your protected health

information without your written authorization in

order to determine eligibility for benefits, seek

reimbursement from a third party, or coordinate

benefits with another health plan under which you

are covered. For example, a health care provider that

provided treatment to you will provide us with

your health information. We use that

information in order to determine whether those

services are eligible for payment under our

group health plan.

Health Care Operations. We use and disclose

your protected health information in order to

perform plan administration functions such as

quality assurance activities, resolution of internal

grievances, and evaluating plan performance. For

example, we review claims experience in order to

understand participant utilization and to make plan

design changes that are intended to control health

care costs.

Treatment. Although the law allows use and

disclosure of your protected health information

for purposes of treatment, as a health plan we

generally do not need to disclose your

information for treatment purposes. Your

physician or health care provider is required to

provide you with an explanation of how they use

and share your health information for purposes

of treatment, payment, and health care

operations.

As permitted or required by law. We may also use

or disclose your protected health information

without your written authorization for other

reasons as permitted by law. We are permitted by

law to share information, subject to certain

requirements, in order to communicate information

on health- related benefits or services that may be

of interest to you, respond to a court order, or

provide information to further public health

activities (e.g., preventing the spread of disease)

without your written authorization. We are also

permitted to share protected health information

during a corporate restructuring such as a merger,

sale, or acquisition. We will also disclose health

information about you when required by law, for

example, in order to prevent serious harm to you

or others.

Pursuant to your Authorization. When required by

law, we will ask for your written authorization before

using or disclosing your protected health

information. If you choose to sign an authorization to

disclose information, you can later revoke that

authorization to prevent any future uses or

disclosures.

To Business Associates. We may enter into

contracts with entities known as Business Associates

that provide services to or perform functions on

behalf of the Plan. We may disclose protected health

information to Business Associates once they have

agreed in writing to safeguard the protected health

information. For example, we may disclose your

protected health information to a Business Associate

to administer claims. Business Associates are also

required by law to protect protected health

information.

To the Plan Sponsor. We may disclose protected

health information to certain employees for the

purpose of administering the Plan. These

employees will use or disclose the protected health

information only as necessary to perform plan

administration functions or as otherwise required

by HIPAA, unless you have authorized additional

disclosures. Your protected health information

cannot be used for employment purposes without

your specific authorization.

Your Rights

Right to Inspect and Copy. In most cases, you have

the right to inspect and copy the protected health

information we maintain about you. If you request

copies, we will charge you a reasonable fee to cover

the costs of copying, mailing, or other expenses

associated with your request. Your request to inspect

or review your health information must be submitted

in writing to the person listed below. In some

circumstances, we may deny your request to inspect

and copy your health information. To the extent

your information is held in an electronic health

record, you may be able to receive the information

in an electronic format.

Right to Amend. If you believe that information

within your records is incorrect or if important

information is missing, you have the right to request

that we correct the existing information or add the

missing information. Your request to amend your

health information must be submitted in writing to

the person listed below. In some circumstances, we

may deny your request to amend your health

information. If we deny your request, you may file a

statement of disagreement with us for inclusion in

any future disclosures of the disputed information.

Right to an Accounting of Disclosures. You have

the right to receive an accounting of certain

disclosures of your protected health information.

The accounting will not include disclosures that

were made (1) for purposes of treatment, payment or

health care operations; (2) to you; (3) pursuant to

your authorization; (4) to your friends or family in

your presence or because of an emergency; (5) for

national security purposes; or (6) incidental to

otherwise permissible disclosures.

Your request to for an accounting must be

submitted in writing to the person listed below.

You may request an accounting of disclosures

made within the last six years. You may request

one accounting free of charge within a 12-month

period.

Right to Request Restrictions. You have the right to

request that we not use or disclose information for

treatment, payment, or other administrative purposes

except when specifically authorized by you, when

required by law, or in emergency circumstances.

You also have the right to request that we limit the

protected health information that we disclose to

someone involved in your care or the payment for

your care, such as a family member or friend.

Your request for restrictions must be submitted in

writing to the person listed below. We will consider

your request, but in most cases are not legally

obligated to agree to those restrictions. However, we

will comply with any restriction request if the

disclosure is to a health plan for purposes of

payment or health care operations (not for

treatment) and the protected health information

pertains solely to a health care item or service that

has been paid for out-of-pocket and in full.

Right to Request Confidential Communications.

You have the right to receive confidential

communications containing your health information.

Your request for restrictions must be submitted in

writing to the person listed below. We are required

to accommodate reasonable requests. For example,

you may ask that we contact you at your place of

employment or send communications regarding

treatment to an alternate address.

Right to be Notified of a Breach. You have the

right to be notified in the event that we (or one of

our Business Associates) discover a breach of

your unsecured protected health information.

Notice of any such breach will be made in

accordance with federal requirements.

Right to Receive a Paper Copy of this Notice. If

you have agreed to accept this notice electronically,

you also have a right to obtain a paper copy of this

notice from us upon request. To obtain a paper copy

of this notice, please contact the person listed

below.

Our Legal Responsibilities

We are required by law to protect the privacy of your protected health information, provide you with certain rights

with respect to your protected health information, provide you with this notice about our privacy practices, and

follow the information practices that are described in this notice.

We may change our policies at any time. In the event that we make a significant change in our policies, we will

provide you with a revised copy of this notice. You can also request a copy of our notice at any time. For more

information about our privacy practices, contact the person listed below.

If you have any questions or complaints, please contact your company’s benefit manager.

Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about

access to your records, you may contact the person listed above. You also may send a written complaint to the U.S.

Department of Health and Human Services — Office of Civil Rights. The person listed above can provide you with

the appropriate address upon request or you may visit www.hhs.gov/ocr for further information. You will not be

penalized or retaliated against for filing a complaint with the Office of Civil Rights or with us.

This form does not constitute legal advice and is provided "as is." This form is based upon current federal law and

is subject to change based upon changes in federal law or subsequent interpretive guidance. This form must be

modified to reflect the user's privacy practices and its state law where the state law is more stringent.

3/03; Revd KMp 3/11 Content © 2010 Zywave, Inc. All rights reserved.