State and Federal Health Plan Disclosures – Human Resources

Notice to Plan Participants – HIPAA 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). In general, 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). However, if you or your dependents lose coverage under Medicaid or a state’s
Children Health Insurance Program (CHIP), or if you or your dependents become eligible for a
premium-assistance subsidy under Medicaid or a CHIP, you have 60 days from the loss of
coverage or the date of eligibility to request enrollment. In addition, if you acquire a new
dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able
to enroll yourself and your dependents in this plan. However, you must request enrollment
within 30 days after the marriage, birth, adoption, or placement for adoption. To request
special enrollment or obtain more information, contact ASR Health Benefits at (616) 957-1751
or (800) 968-2449.

Women’s Health and Cancer Rights Act of 1998 (Also Known As Janet’s Law)
Did you know that your health plan, as required by the Women’s Health and Cancer Rights Act of
1998, provides benefits for mastectomy-related services? These services include
reconstruction and surgery to achieve symmetry between the breasts, prostheses, and treatment of
complications resulting from a mastectomy (including lymphedema). Call your Claim
Administrator at (616) 957-1751 or 1-800-968-2449 for more information.

Notice of Qualified Health Coverage for Purposes of Michigan No-Fault Auto Law
(Michigan Residents Only)

This Notice contains important information that you’ll need to know when you purchase
or renew an auto insurance policy in the State of Michigan. You should show this Notice to your
auto insurance agent so that he or she can help you construct a policy that meets your needs.

Under Michigan no-fault auto law, when you purchase or renew your auto insurance policy after July
1, 2020 you won’t automatically receive unlimited, lifetime Personal Insurance Protection (PIP)
medical coverage. Instead, you’ll be able to choose from a menu of PIP medical coverage levels.
Your auto insurance agent will be able to explain the pros and cons of each one. When considering
how much PIP medical coverage to purchase, it’s critical to keep these points in mind:

• Kalamazoo College’s health plan (the “Plan”) pays primary on Michigan
enrollees’ auto-related claims, and given current deductible requirements constitutes
“qualified health coverage” as defined in Michigan Compiled Laws 500.3107d(7)(b)(i).

• Coverage of auto accident-related claims under any employment-based plan is available
only as long as you remain employed/enrolled AND that plan continues to cover Michigan enrollees’
auto claims. In contrast, the amount of PIP medical coverage on your policy at the time
of an auto accident remains available to you until the maximum payout per accident (if any)
is exhausted, no matter how long that takes.

• Most types of care are covered under both the Plan and PIP medical. However, PIP medical
covers additional services that employment-based plans typically do not. Your auto
insurance agent can explain what those services are.

You’re urged to carry enough PIP coverage on your auto policy to protect yourself and
your family from financial catastrophe in the event that there are claims for auto
accident-related services that the Plan doesn’t cover, or if you or any of your family members
cease to be enrolled in the Plan.

Contact your auto insurance agent immediately if you or any of your family members cease to be
enrolled in the Plan, or if the Plan ceases to constitute “qualified health coverage.”
An adjustment to your auto policy may be required, and you may have a limited amount of time to
make it.

NOTE: This notice is correct at the time of this writing but may not reflect recent changes to plan
coverage. For more information, call ASR Health Benefits at (616) 957-1751 or (800) 968-2449.

Notice of Creditable Coverage Important Notice about Your Prescription Drug Coverage and Medicare

This Notice affects individuals who are enrolled in or eligible to enroll in Medicare. You or a
family member may be enrolled in Medicare owing to age (on or after attaining age 65), a
disability, or permanent kidney failure (end-stage renal disease). If no one in your family is
enrolled in or eligible to enroll in Medicare, the information in this Notice does NOT apply to
you.
This Notice provides information about your current prescription drug coverage under the Health
Benefit Plan offered by Kalamazoo College (Employer) and the prescription drug coverage for people
with Medicare. You may receive this Notice or an updated version of this Notice on an annual
basis. You may also request an additional copy of this Notice at any time.
For further information about this Notice or your coverage under the Health Benefit Plan, you may
contact Employer at the following address or telephone number:
Kalamazoo College Renee Boelcke
1200 Academy Street
Kalamazoo, Michigan 49006
269.337.7248
If this Notice applies to you or a family member, you should read it carefully and keep it where
you can find it.

Information You Need to Know about Medicare Prescription Drug Coverage

Medicare prescription drug coverage became available in 2006 to everyone who
is eligible for Medicare. You can get this coverage if you join a Medicare prescription drug plan
or a Medicare Advantage plan (like an HMO or PPO) that offers prescription drug coverage.
You can join a Medicare prescription drug plan or Medicare Advantage plan when you first
become eligible for Medicare and each year from October 15 through December 7. In addition, if
you lose coverage through Employer through no fault of your own, you will be eligible to sign
up for a Medicare prescription drug plan at that time, through a special two-month enrollment
period.
All Medicare prescription 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.
Medicare beneficiaries will need to carefully review the materials provided by each
prescription drug plan available to them to determine whether it provides the coverage they need.

Information You Need to Know about Employer’s Prescription Drug Coverage

Employer currently offers eligible employees and their eligible dependents prescription
drug coverage under the Health Benefit Plan. Participants in the Health Benefit Plan who are
enrolled in, or eligible for, Medicare can continue their coverage under the Health
Benefit Plan.

Employer has determined that the prescription drug coverage offered under the
Health Benefit Plan is, on average for all plan participants, expected to pay as much
as the standard Medicare prescription drug coverage will pay. In other words, for
most people, the prescription drug coverage under the Health Benefit Plan is at least as good as
the coverage you can get from a Medicare prescription drug plan, which means this
coverage is “creditable coverage.” As a result, participants in the Health Benefit Plan who
are also enrolled in or eligible to enroll in Medicare can keep their current coverage
under the Health Benefit Plan and not pay a higher premium if they later decide to enroll in a
Medicare prescription drug plan.

Frequently Asked Questions

If I decide to enroll in a Medicare prescription drug plan, can I also keep my
coverage under the Health Benefit Plan?
Yes. Enrollment in a Medicare prescription drug plan will generally not affect your
eligibility for coverage under the Health Benefit Plan. However, as long as you are actively
working for Employer, coverage under the Health Benefit Plan will usually be your primary coverage.
Therefore, you may not need to enroll in a Medicare prescription drug plan while you are actively
working for Employer.
If I decide to drop my coverage under the Health Benefit Plan and enroll in a Medicare prescription
drug plan and Medicare Parts A and B, can I re-enroll in the Health Benefit Plan if I later decide
I do not like the Medicare plan?
Yes. However, if you drop coverage under the Health Benefit Plan, you will generally not be able
to re-enroll until the next open enrollment period.
Before dropping coverage under the Health Benefit Plan, you should consider that your
coverage under the Health Benefit Plan pays for other health expenses in addition to
prescription drugs, which may or may not be covered under Medicare Parts A and B and the Medicare
prescription drug coverage to the same extent that they are covered under the Health
Benefit Plan.
You should compare your current coverage under the Health Benefit Plan with the coverage and cost
of the Medicare prescription drug coverage plans providing coverage in your area (and Medicare
Parts A and B) before deciding whether to drop coverage under the Health Benefit Plan.
What happens if I elect to keep my coverage under the Health Benefit Plan and not enroll in
Medicare prescription drug coverage until I leave Employer?
Because the prescription drug coverage under the Health Benefit Plan is, on average for all plan
participants, expected to pay as much as the standard Medicare prescription drug
coverage will pay, it is considered “creditable coverage.” As a result, you can choose to join a
Medicare prescription drug plan later without paying a higher premium (a penalty).
Each year, Medicare beneficiaries will have the opportunity to enroll in a Medicare
prescription drug plan between October 15 and December 7. You will also be entitled to a special
two-month enrollment period if your coverage under the Health Benefit Plan ends through
no fault of your own. However, individuals who drop or lose coverage under the Health Benefit
Plan but do not enroll in Medicare prescription drug coverage within a certain period of time may
pay more to enroll in Medicare prescription drug coverage later.

If you go 63 continuous days or longer without prescription drug coverage that is at least as good
as Medicare’s prescription drug coverage (i.e., creditable coverage), your monthly premium
may increase by at least 1 percent of the Medicare base premium per month for every
month that you did not have creditable coverage. For example, if you go 19 months without
creditable coverage, your premium will always be at least 19 percent higher than the Medicare base
premium. You may pay this higher premium (a penalty) as long as you have Medicare coverage. In
addition, you may have to wait until the next October to enroll.

Where can I get more information about my options under Medicare prescription drug
coverage?

More detailed information about Medicare plans that offer prescription drug coverage will be
available in the “Medicare & You” handbook. Medicare beneficiaries will get a copy of the handbook
in the mail every year from Medicare; representatives from Medicare prescription drug plans may
also contact beneficiaries directly. More information about Medicare prescription drug
plans is also available as follows:

Visit www.medicare.gov.
Call your State Health Insurance Assistance Program (see your copy of the “Medicare & You”
handbook for the telephone number).
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 a Medicare prescription
drug plan is available. For information about this extra help, visit the Social Security
Administration online at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY
1-800-325-0778).

Remember: Keep this Notice. If you decide to enroll in a Medicare prescription drug plan, you may
be required to provide a copy of this Notice when you join to show whether you have maintained
creditable coverage and whether you are required to pay a higher premium (a penalty).

Notice of Creditable Coverage for Retirees
Important Notice about Your Prescription Drug Coverage and Medicare

This Notice affects individuals who are enrolled in or eligible to enroll in Medicare. You or a
family member may be enrolled in Medicare owing to age (on or after attaining age 65), a
disability, or permanent kidney failure (end-stage renal disease). If no one in your family is
enrolled in or eligible to enroll in Medicare, the information in this Notice does NOT apply to
you.
This Notice provides information about your current retiree prescription drug coverage under the
Health Benefit Plan offered by Kalamazoo College (Employer) and the prescription drug
coverage for people with Medicare. You may receive this Notice or an updated version of this
Notice on an annual basis. You may also request an additional copy of this Notice at any time.
For further information about this Notice or your retiree coverage under the Health Benefit Plan,
you may contact Employer at the following address or telephone number:
Kalamazoo College Renee Boelcke
1200 Academy Street
Kalamazoo, Michigan 49006
269.337.7248
If this Notice applies to you or a family member, you should read it carefully and keep it where
you can find it.

Information You Need to Know about Medicare Prescription Drug Coverage

Information You Need to Know about Employer’s Prescription Drug Coverage

Employer currently offers eligible retirees and their eligible dependents prescription
drug coverage under the Health Benefit Plan. Retirees and their dependents who are enrolled in, or
eligible for, Medicare can continue their coverage under the Health Benefit Plan. They do not need
to enroll in a Medicare prescription drug plan.

Employer has determined that the prescription drug coverage available to retirees under
the Health Benefit Plan is, on average for all retirees, expected to pay as much as
the standard Medicare prescription drug coverage will pay. In other words, for most
people, the retiree prescription drug coverage under the Health Benefit Plan is at least as good
as the coverage you can get from a Medicare prescription drug plan, which means this coverage
is “creditable coverage.” As a result, retirees and their dependents who are also
enrolled in or eligible to enroll in Medicare can keep their current coverage under the
Health Benefit Plan and not pay a higher premium if they later decide to enroll in a Medicare
prescription drug plan.

Frequently Asked Questions

If I decide to enroll in a Medicare prescription drug plan, can I also keep my
coverage under the Health Benefit Plan?
Yes. You can enroll in a Medicare prescription drug plan and keep your coverage under the Health
Benefit Plan. Enrollment in a Medicare prescription drug plan will generally not affect
your eligibility to receive coverage under the Health Benefit Plan. However, Medicare will be the
primary coverage for your prescription drug expenses. Therefore, you may not need to have
coverage under both the Health Benefit Plan and a Medicare prescription drug plan.
You should compare your current coverage under the Health Benefit Plan with the coverage and cost
of the Medicare prescription drug coverage plans providing coverage in your area before deciding
whether to enroll in a Medicare prescription drug plan and whether to keep coverage under the
Health Benefit Plan.
If I decide to drop my coverage under the Health Benefit Plan because I am enrolling in a Medicare
prescription drug plan, can I re-enroll in the Health Benefit Plan if I later decide I do not like
the Medicare plan?
Yes. However, you will generally not be able to re-enroll in the Health Benefit Plan until the
next open enrollment period.
Before dropping coverage under the Health Benefit Plan, you should consider that your
coverage under the Health Benefit Plan pays for other health expenses in addition to
prescription drugs, which may or may not be covered under Medicare Parts A and B to the same extent
that they are covered under the Health Benefit Plan.
What happens if I elect to keep my coverage under the Health Benefit Plan now, but
I want to enroll in Medicare prescription drug coverage at some time in the future?
Because the prescription drug coverage under the Health Benefit Plan is, on average for all
retirees, expected to pay as much as the standard Medicare prescription drug coverage will pay, it
is considered “creditable coverage.” As a result, you can choose to join a Medicare prescription
drug plan later without paying a higher premium (a penalty).
Each year, Medicare beneficiaries will have the opportunity to enroll in a Medicare
prescription drug plan between October 15 and December 7. You will also be entitled to a special
two-month enrollment period if your coverage under the Health Benefit Plan ends through
no fault of your own. However, individuals who drop or lose coverage under the Health Benefit
Plan but do not enroll in Medicare prescription drug coverage within a certain period of time may
pay more to enroll in Medicare prescription drug coverage later.

Where can I get more information about my options under Medicare prescription drug
coverage?

Visit www.medicare.gov.
Call your State Health Insurance Assistance Program (see your copy of the “Medicare & You”
handbook for the telephone number).
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Remember: Keep this Notice. If you decide to enroll in a Medicare prescription drug plan, you may
be required to provide a copy of this Notice when you join to show whether you tained creditable
coverage and whether you are required to pay a higher
premium (a penalty).

Your Rights and Protections Against Surprise Medical Bills (Effective January 1, 2022)

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are
protected from surprise billing or balance billing.

What is balance billing (sometimes called surprise billing)?
When you see a doctor or other health-care provider, you may owe certain out-of-pocket
costs, such as a co-payment, coinsurance, or a deductible. You may have other costs or
have to pay the entire bill if you see a provider or visit a health-care facility that isn’t in your
health plan’s network.

Out-of-network describes providers and facilities that haven’t signed a contract with your
health plan. Out-of-network providers may be permitted to bill you for the difference between
what your plan agreed to pay and the full amount charged for a service. This amount is
called balance billing and is likely more than in-network costs for the same service and
might not count toward your annual out-of-pocket limit.

Surprise billing is an unexpected balance bill that can happen when you can’t control who is
involved in your care—like when you have an emergency or when you schedule a visit at an
in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for the following:

Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network
provider or facility, the most the provider or facility may bill you is your plan’s in-network
cost-sharing amount (such as co-payments and coinsurance). You can’t be balance
billed for these emergency services, including services you may get after you’re in stable
condition, unless you give written consent and give up your protections not to be balanced
billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain
providers there may be out-of-network. In these cases, the most those providers may bill you
is your plan’s in-network cost-sharing amount. This mandate applies to emergency
medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeons,
hospitalists, or intensivist services. These providers can’t balance bill you and may not ask
you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance
bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t
required to get care out-of-network. You can choose a provider or facility in your
plan’s network.

When balance billing isn’t allowed, you also have the following protections:
• You are responsible for paying only your share of the cost (like the co-payments,
coinsurance, and deductibles that you would pay if the provider or facility was in-network).
Your health plan will pay out-of-network providers and facilities directly.
• Your health plan must generally do the following:
o Cover emergency services without requiring you to get approval for services in advance (prior authorization).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the U.S. Department of Labor at (866) 444-3272. Visit www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act for more information about your rights under federal law.

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

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your
state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP
programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance
programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more
information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below, contact your state
Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents
might be eligible for either of these programs, contact your state Medicaid or CHIP office or dial 1-877-KIDS NOW or
www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay
the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your
employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a
“special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for
premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at
www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan
premiums. The following list of states is current as of July 31, 2021. Contact your state for more information on
eligibility.

ALABAMA – Medicaid
Website: http://myalhipp.com/
Phone: 1-855-692-5447
ALASKA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/
default.aspx
ARKANSAS – Medicaid
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
CALIFORNIA – Medicaid
Website: Health Insurance Premium Payment (HIPP) Program
http://dhcs.ca.gov/hipp
Phone: 916-445-8322
Email: hipp@dhcs.ca.gov
COLORADO – Health First Colorado (Colorado’s Medicaid
Program) & Child Health Plan Plus (CHP+)
Health First Colorado Website: https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center: 1-800-221-3943/
State Relay 711
CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus
CHP+ Customer Service: 1-800-359-1991/ State Relay 711
Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/
pacific/hcpf/health-insurancebuy-
program
HIBI Customer Service: 1-855-692-6442
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
flmedicaidtplrecovery.com/hipp/index.html
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: https://medicaid.georgia.gov/health-insurance-premiumpayment-
program-hipp
Phone: 678-564-1162 Ext. 2131
INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/
Phone: 1-877-438-4479
All Other Medicaid
Website: https://www.in.gov/medicaid/
Phone 1-800-457-4584
IOWA – Medicaid and CHIP (Hawki)
Medicaid Website: https://dhs.iowa.gov/ime/members
Medicaid Phone: 1-800-338-8366
Hawki Website: http://dhs.iowa.gov/Hawki
Hawki Phone: 1-800-257-8563
HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp
HIPP Phone: 1-888-346-9562
KANSAS – Medicaid
Website: https://www.kancare.ks.gov/
Phone: 1-800-792-4884
KENTUCKY – Medicaid
Kentucky Integrated Health Insurance Premium Payment Program
(KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/
kihipp.aspx
Phone: 1-855-459-6328
Email: KIHIPP.PROGRAM@ky.gov
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx
Phone: 1-877-524-4718
Kentucky Medicaid Website: https://chfs.ky.gov
LOUISIANA – Medicaid
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp
Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
MAINE – Medicaid
Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms
Phone: 1-800-442-6003
TTY: Maine relay 711
Private Health Insurance Premium Webpage:
https://www.maine.gov/dhhs/ofi/applications-forms
Phone: 1-800-977-6740
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
Website: https://www.mass.gov/info-details/masshealth-premiumassistance-
pa
Phone: 1-800-862-4840
MINNESOTA – Medicaid
Website: https://mn.gov/dhs/people-we-serve/children-and-families/
health-care/health-care-programs/programs-and-services/
other-insurance.jsp
Phone: 1-800-657-3739
MISSOURI – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
MONTANA – Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084
NEBRASKA – Medicaid
Website: http://www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
Lincoln: 402-473-7000
Omaha: 402-595-1178
NEVADA – Medicaid
Medicaid Website: http://dhcfp.nv.gov
Medicaid Phone: 1-800-992-0900
NEW HAMPSHIRE – Medicaid
Website: https://www.dhhs.nh.gov/oii/hipp.htm
Phone: 603-271-5218
Toll free number for the HIPP program: 1-800-852-3345, ext. 5218
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/
medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NEW YORK – Medicaid
Website: https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-541-2831
NORTH CAROLINA – Medicaid
Website: https://medicaid.ncdhhs.gov/
Phone: 919-855-4100
NORTH DAKOTA – Medicaid
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
OREGON – Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/
HIPP-Program.aspx
Phone: 1-800-692-7462
RHODE ISLAND – Medicaid and CHIP
Website: http://www.eohhs.ri.gov/
Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)
SOUTH CAROLINA – Medicaid
Website: https://www.scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA – Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
TEXAS – Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
UTAH – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT – Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
VIRGINIA – Medicaid and CHIP
Website: https://www.coverva.org/en/famis-select
https://www.coverva.org/en/hipp
Medicaid Phone: 1-800-432-5924
CHIP Phone: 1-800-432-5924
WASHINGTON – Medicaid
Website: https://www.hca.wa.gov/
Phone: 1-800-562-3022
WEST VIRGINIA – Medicaid
Website: http://mywvhipp.com/
Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
WISCONSIN – Medicaid and CHIP
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-800-362-3002
WYOMING – Medicaid
Website: https://health.wyo.gov/healthcarefin/medicaid/programs-andeligibility/
Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2021, or for more information on special
enrollment rights, contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/agencies/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

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a
collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.
The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by
OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a
collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also,
notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of
information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per
respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this
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Glossary of Health Coverage and Medical Terms

This glossary defines many commonly used terms, but isn’t a full list. These glossary terms
and definitions are intended to be educational and may be different from the terms and definitions
in your plan or health insurance policy. Some of these terms also might not have exactly the same
meaning when used in your policy or plan, and in any case, the policy or plan governs. (See your
Summary of Benefits and Coverage for information on how to get a copy of your policy or plan
document.)
• Underlined text indicates a term defined in this Glossary.
• See below for an example showing how deductibles, coinsurance and out-of-pocket limits work
together in a real life situation.

Allowed Amount
This is the maximum payment the plan will pay for a covered health care service. May also be called
“eligible expense,” “payment allowance,” or “negotiated rate.”

Appeal
A request that your health insurer or plan review a decision that denies a benefit or payment
(either in whole or in part).

Balance Billing
When a provider bills you for the balance remaining on the bill that your plan doesn’t cover. This
amount is the difference between the actual billed amount and the allowed amount. For example, if
the provider’s charge is $200 and the allowed amount is $110, the provider may bill you for the remaining $90. This happens most often when you see an out-of-network provider (non-preferred provider). A network provider
(preferred provider) may not bill you for covered services.

Claim
A request for a benefit (including reimbursement of a health care expense) made by you or your
health care provider to your health insurer or plan for items or services you think are covered.

Coinsurance
Your share of the costs of a covered health care service, calculated as a percentage (for example,
20%) of the allowed amount for the service. You generally pay coinsurance plus any deductibles you
owe. (For example, if the health insurance or plan’s allowed amount for an office visit is $100
and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health
insurance or plan pays the rest of the allowed amount.)

Complications of Pregnancy
Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm
to the health of the mother or the fetus. Morning sickness and a non- emergency caesarean section
generally aren’t complications of pregnancy.

Copayment
A fixed amount (for example, $15) you pay for a covered health care service, usually when you
receive the service sometimes called “copay”). The amount can vary by the type of covered health
care service.

Cost Sharing
Your share of costs for services that a plan covers that you must pay out of your own pocket
(sometimes called “out-of-pocket costs”). Some examples of cost sharing are copayments,
deductibles, and coinsurance. Family cost sharing is the share of cost for deductibles and out-
of-pocket costs you and your spouse and/or child(ren) must pay out of your own pocket. Other costs,
including your premiums, penalties you may have to pay, or the cost of care a plan doesn’t cover
usually aren’t considered cost sharing.

Cost-sharing Reductions
Discounts that reduce the amount you pay for certain services covered by an individual plan you buy
through the Marketplace. You may get a discount if your income is below a certain level, and you
choose a Silver level health plan or if you’re a member of a federally- recognized tribe, which
includes being a shareholder in an Alaska Native Claims Settlement Act corporation.

Deductible
An amount you could owe during a coverage period (usually one year) for covered health care
services before your plan begins to pay. An overall deductible applies to all or almost all covered
items and services. A plan with an overall deductible may
also have separate deductibles that apply to specific services or groups of services. A plan may
also have only separate deductibles. (For example, if your deductible is
$1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care
services subject to the deductible.)

Diagnostic Test
Tests to figure out what your health problem is. For example, an x-ray can be a diagnostic test to
see if you have a broken bone.

Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use. DME may
include: oxygen equipment, wheelchairs, and crutches.

Emergency Medical Condition
An illness, injury, symptom (including severe pain), or condition severe enough to risk serious
danger to your health if you didn’t get medical attention right away. If you didn’t get immediate
medical attention you could reasonably expect one of the following: 1) Your health would be put in
serious danger; or 2) You would have serious problems with your bodily functions; or 3) You would
have serious damage to any part or organ of your body.

Emergency Medical Transportation
Ambulance services for an emergency medical condition. Types of emergency medical transportation
may include transportation by air, land, or sea. Your plan may not cover all types of emergency
medical transportation, or may pay less for certain types.
Emergency Room Care / Emergency Services Services to check for an emergency medical condition and
treat you to keep an emergency medical condition from getting worse. These services may be provided
in a licensed hospital’s emergency room or other place that provides care for emergency medical
conditions.

Excluded Services
Health care services that your plan doesn’t pay for or cover.

Formulary
A list of drugs your plan covers. A formulary may include how much your share of the cost is for
each drug. Your plan may put drugs in different cost-sharing levels or tiers. For example, a
formulary may include generic drug and brand name drug tiers and different cost- sharing amounts
will apply to each tier.

Grievance
A complaint that you communicate to your health insurer or plan.

Habilitation Services
Health care services that help a person keep, learn or improve skills and functioning for daily
living. Examples include therapy for a child who isn’t walking or talking at the expected age.
These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance
A contract that requires a health insurer to pay some or all of your health care costs in exchange
for a premium. A health insurance contract may also be called a “policy” or “plan.”

Home Health Care
Health care services and supplies you get in your home under your doctor’s orders. Services may be
provided by nurses, therapists, social workers, or other licensed health care providers. Home
health care usually doesn’t include help with non-medical tasks, such as cooking, cleaning, or
driving.

Hospice Services
Services to provide comfort and support for persons in the last stages of a terminal illness and
their families.

Hospitalization
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
Some plans may consider an overnight stay for observation as outpatient care instead of inpatient
care.

Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.

In-network Coinsurance
Your share (for example, 20%) of the allowed amount for covered health care services. Your share is
usually lower for in-network covered services.

In-network Copayment
A fixed amount (for example, $15) you pay for covered health care services to providers who
contract with your health insurance or plan. In-network copayments usually are less than
out-of-network copayments.

Marketplace
A marketplace for health insurance where individuals, families and small businesses can learn about
their plan options; compare plans based on costs, benefits and other important features; apply for
and receive financial help with premiums and cost sharing based on income; and choose a plan and
enroll in coverage. Also known as an “Exchange.” The Marketplace is run by the state in some states
and by the federal government in others. In some states, the Marketplace also helps eligible
consumers enroll in other programs, including Medicaid and the Children’s Health Insurance Program
(CHIP). Available online, by phone, and in-person.

Maximum Out-of-pocket Limit
Yearly amount the federal government sets as the most each individual or family can be required to
pay in cost sharing during the plan year for covered, in-network services. Applies to most types of
health plans and insurance. This amount may be higher than the out-of- pocket limits stated for
your plan.

Medically Necessary
Health care services or supplies needed to prevent, diagnose, or treat an illness, injury,
condition, disease, or its symptoms, including habilitation, and that meet accepted standards of
medicine.

Minimum Essential Coverage
Minimum essential coverage generally includes plans, health insurance available through the
Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain
other coverage. If you are eligible for certain types of minimum essential coverage, you may not be
eligible for the premium tax credit.

Minimum Value Standard
A basic standard to measure the percent of permitted costs the plan covers. If you’re offered an
employer plan that pays for at least 60% of the total allowed costs of benefits, the plan offers
minimum value and you may not qualify for premium tax credits and cost-sharing reductions to buy a
plan from the Marketplace.

Network
The facilities, providers and suppliers your health insurer or plan has contracted with to provide
health care services.

Network Provider (Preferred Provider)
A provider who has a contract with your health insurer or plan who has agreed to provide services
to members of a plan. You will pay less if you see a provider in the network. Also called
“preferred provider” or “participating provider.”

Orthotics and Prosthetics
Leg, arm, back and neck braces, artificial legs, arms, and eyes, and external breast prostheses
after a mastectomy. These services include: adjustment, repairs, and replacements required because
of breakage, wear, loss, or a change in the patient’s physical condition.

Out-of-network Coinsurance
Your share (for example, 40%) of the allowed amount for covered health care services to providers
who don’t contract with your health insurance or plan. Out-of- network coinsurance usually costs
you more than in- network coinsurance.

Out-of-network Copayment
A fixed amount (for example, $30) you pay for covered health care services from providers who do
not contract with your health insurance or plan. Out-of-network copayments usually are more than
in-network copayments.

Out-of-network Provider (Non-Preferred Provider)
A provider who doesn’t have a contract with your plan to provide services. If your plan covers
out-of-network services, you’ll usually pay more to see an out-of-network provider than a preferred
provider. Your policy will explain what those costs may be. May also be called “non-preferred” or
“non-participating” instead of “out- of-network provider.”

Out-of-pocket Limit The most you could pay during a coverage period (usually one year) for your
share of the costs of covered services. After you meet this limit the plan will usually pay 100% of the allowed amount. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges or health care
your plan doesn’t cover. Some plans don’t count all of your copayments, deductibles, coinsurance
payments, out-of- network payments, or other expenses toward this limit.

Physician Services
Health care services a licensed medical physician, including an M.D. (Medical Doctor) or D.O.
(Doctor of Osteopathic Medicine), provides or coordinates.

Plan
Health coverage issued to you directly (individual plan) or through an employer, union or other
group sponsor (employer group plan) that provides coverage for certain health care costs. Also
called “health insurance plan,” “policy,” “health insurance policy,” or “health insurance.”

Preauthorization
A decision by your health insurer or plan that a health care service, treatment plan, prescription
drug or durable medical equipment (DME) is medically necessary.
Sometimes called “prior authorization,” “prior approval,” or “precertification.” Your health
insurance or plan may require preauthorization for certain services before you receive them, except
in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the
cost.

Premium
The amount that must be paid for your health insurance or plan. You and/or your employer usually
pay it monthly, quarterly, or yearly.

Premium Tax Credits
Financial help that lowers your taxes to help you and your family pay for private health insurance.
You can get this help if you get health insurance through the Marketplace and your income is below
a certain level.
Advance payments of the tax credit can be used right away to lower your monthly premium costs.

Prescription Drug Coverage
Coverage under a plan that helps pay for prescription drugs. If the plan’s formulary uses “tiers”
(levels), prescription drugs are grouped together by type or cost. The amount you’ll pay in cost
sharing will be different for each “tier” of covered prescription drugs.

Prescription Drugs
Drugs and medications that by law require a prescription.

Preventive Care (Preventive Service)
Routine health care, including screenings, check-ups, and patient counseling, to prevent or
discover illness, disease, or other health problems.

Primary Care Physician
A physician, including an M.D. (Medical Doctor) or
D.O. (Doctor of Osteopathic Medicine), who provides or coordinates a range of health care services
for you.

Primary Care Provider
A physician, including an M.D. (Medical Doctor) or
D.O. (Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician
assistant, as allowed under state law and the terms of the plan, who provides, coordinates, or
helps you access a range of health care services.

Provider
An individual or facility that provides health care services. Some examples of a provider include a
doctor, nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing
facility, and rehabilitation center. The plan may require the provider to be licensed, certified,
or accredited as required by state law.

Reconstructive Surgery
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth
defects, accidents, injuries, or medical conditions.

Referral
A written order from your primary care provider for you to see a specialist or get certain health
care services. In many health maintenance organizations (HMOs), you need to get a referral before
you can get health care services from anyone except your primary care provider. If you don’t get a
referral first, the plan may not pay for the services.

Rehabilitation Services
Health care services that help a person keep, get back, or improve skills and functioning for daily
living that have been lost or impaired because a person was sick, hurt, or disabled. These services
may include physical and occupational therapy, speech-language pathology, and psychiatric
rehabilitation services in a variety of inpatient and/or outpatient settings.

Screening
A type of preventive care that includes tests or exams to detect the presence of something, usually
performed when you have no symptoms, signs, or prevailing medical history of a disease or
condition.

Skilled Nursing Care
Services performed or supervised by licensed nurses in your home or in a nursing home. Skilled
nursing care is not the same as “skilled care services,” which are services performed by therapists
or technicians (rather than licensed nurses) in your home or in a nursing home.

Specialist
A provider focusing on a specific area of medicine or a group of patients to diagnose, manage,
prevent, or treat certain types of symptoms and conditions.

Specialty Drug
A type of prescription drug that, in general, requires special handling or ongoing monitoring and
assessment by a health care professional, or is relatively difficult to dispense. Generally,
specialty drugs are the most expensive drugs on a formulary.

UCR (Usual, Customary and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area
usually charge for the same or similar medical service. The UCR amount sometimes is used to
determine the allowed amount.

Urgent Care
Care for an illness, injury, or condition serious enough that a reasonable person would seek care
right away, but not so severe as to require emergency room care.