| 49 | HIPAA Notice of Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after marriage. You must request enrollment within 60 days of birth, adoption, placement for adoption, loss of eligibility for Medicaid or Children’s Health Insurance Program (CHIP) or becomes eligible for subsidy (state premium assistance program). To request special enrollment or obtain more information, contact UnityPoint Health’s AskHR department by calling 1-888- 543-2275. Women’s Health And Cancer Rights Act of 1998 (WHCRA) Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema? Call HealthPartners Member Services at (888) 735-9200 for more information. No Surprise Act Notice Federal law requires health insurance issuers offering group health insurance coverage to make available a notice to team members informing them of federal restrictions on balance billing and the requirements under Code 9816, ERISA section 716, and PHS Act second 2799A-1. The No Surprise Act Notice also lets you know how you may contact appropriate state or federal agencies if a provider or facility has violated the restrictions against balance billing. 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 in the CHIP notice, 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 states listed in the CHIP notice, you may be eligible for assistance paying your employer health plan premiums. Contact your state using the contact information provided here for more information on eligibility.