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Important Notice from School District of South Milwaukee About

Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with School District of South Milwaukee and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area.  Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. 

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare.  You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare.  Some plans may also offer more coverage for a higher monthly premium. 

2. School District of South Milwaukee has determined that the prescription drug coverage offered by the [UnitedHealth care plan] is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage.  Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. 

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. 

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. 

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? 

If you decide to join a Medicare drug plan, your current School District of South Milwaukee coverage will not be affected.  Your current coverage pays for other health expenses in addition to prescription drugs.  If you enroll in a Medicare prescription drug plan, you and your eligible dependents will still be eligible to receive all of your current health and prescription drug benefits. 

If you do decide to join a Medicare drug plan and drop your current School District of South Milwaukee coverage, be aware that you and your dependents may not be able to get this coverage back. 

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? 

You should also know that if you drop or lose your current coverage with School District of South Milwaukee and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. 

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage.  For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium.  You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. 

For More Information About This Notice Or Your Current Prescription Drug Coverage… 

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through School District of South Milwaukee changes. You also may request a copy of this notice at any time. 

For More Information About Your Options Under Medicare Prescription Drug Coverage… 

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

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov  

• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help 

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. 

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). 

 

Remember:  Keep this Creditable Coverage notice.  If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

 

Date: February 17, 2025

Name of Entity/Sender: School District of South Milwaukee

Contact--Position/Office: Gaye Tonar – Payroll & Benefits Specialist 

Address: 901 15th Avenue, South Milwaukee, WI 53172

Phone Number: (414) 766-5025

 

Notice of School District of South Milwaukee

Health Information Privacy 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. 

 

 

The School District of South Milwaukee (the “Plan”) provides health benefits to eligible employees of the District (the “Company”) and their eligible dependents as described in the summary plan description(s) for the Plan.  The Plan creates, receives, uses, maintains and discloses health information about participating employees and dependents in the course of providing these health benefits. 

For ease of reference, in the remainder of this Notice, the words “you,” “your,” and “yours” refers to any individual with respect to whom the Plan receives, creates or maintains Protected Health Information, including employees, [retirees,] and COBRA qualified beneficiaries, if any, and their respective dependents. 

The Plan is required by law to take reasonable steps to protect your Protected Health Information from inappropriate use or disclosure. 

Your “Protected Health Information” (PHI) is information about your past, present, or future physical or mental health condition, the provision of health care to you, or the past, present, or future payment for health care provided to you, but only if the information identifies you or there is a reasonable basis to believe that the information could be used to identify you.  Protected health information includes information of a person living or deceased (for a period of fifty years after the death.) 

The Plan is required by law to provide notice to you of the Plan’s duties and privacy practices with respect to your PHI, and is doing so through this Notice.  This Notice describes the different ways in which the Plan uses and discloses PHI.  It is not feasible in this Notice to describe in detail all of the specific uses and disclosures the Plan may make of PHI, so this Notice describes all of the categories of uses and disclosures of PHI that the Plan may make and, for most of those categories, gives examples of those uses and disclosures. 

The Plan is required to abide by the terms of this Notice until it is replaced.  The Plan may change its privacy practices at any time and, if any such change requires a change to the terms of this Notice, the Plan will revise and re-distribute this Notice according to the Plan’s distribution process.  Accordingly, the Plan can change the terms of this Notice at any time.  The Plan has the right to make any such change effective for all of your PHI that the Plan creates, receives or maintains, even if the Plan received or created that PHI before the effective date of the change. 

The Plan is distributing this Notice, and will distribute any revisions, only to participating employees [and retirees] and COBRA qualified beneficiaries, if any.  If you have coverage under the Plan as a dependent of an employee, [retiree] or COBRA qualified beneficiary, you can get a copy of the Notice by requesting it from the contact named at the end of this Notice. 

Please note that this Notice applies only to your PHI that the Plan maintains.  It does not affect your doctor’s or other health care provider’s privacy practices with respect to your PHI that they maintain. 

Receipt of Your PHI by the Company and Business Associates 

The Plan may disclose your PHI to, and allow use and disclosure of your PHI by, the Company and Business Associates, and any of their subcontractors without obtaining your authorization. 

Plan Sponsor:  The Company is the Plan Sponsor and Plan Administrator.  The Plan may disclose to the Company, in summary form, claims history and other information so that the Company may solicit premium bids for health benefits, or to modify, amend or terminate the Plan.  This summary information omits your name and Social Security Number and certain other identifying information.  The Plan may also disclose information about your participation and enrollment status in the Plan to the Company and receive similar information from the Company.  If the Company agrees in writing that it will protect the information against inappropriate use or disclosure, the Plan also may disclose to the Company a limited data set that includes your PHI, but omits certain direct identifiers, as described later in this Notice. 

The Plan may disclose your PHI to the Company for plan administration functions performed by the Company on behalf of the Plan, if the Company certifies to the Plan that it will protect your PHI against inappropriate use and disclosure. 

Example:  The Company reviews and decides appeals of claim denials under the Plan.  The Claims Administrator provides PHI regarding an appealed claim to the Company for that review, and the Company uses PHI to make the decision on appeal. 

Business Associates:  The Plan and the Company hire third parties, such as a third party administrator (the “Claims Administrator”), to help the Plan provide health benefits.  These third parties are known as the Plan’s 

“Business Associates.”  The Plan may disclose your PHI to Business Associates, like the Claims Administrator, who are hired by the Plan or the Company to assist or carry out the terms of the Plan.  In addition, these Business Associates may receive PHI from third parties or create PHI about you in the course of carrying out the terms of the Plan.  The Plan and the Company must require all Business Associates to agree in writing that they will protect your PHI against inappropriate use or disclosure, and will require their subcontractors and agents to do so, too. 

 

For purposes of this Notice, all actions of the Company and the Business Associates that are taken on behalf of the 

Plan are considered actions of the Plan.  For example, health information maintained in the files of the Claims Administrator is considered maintained by the Plan.  So, when this Notice refers to the Plan taking various actions with respect to health information, those actions may be taken by the Company or a Business Associate on behalf of the Plan. 

How the Plan May Use or Disclose Your PHI 

The Plan may use and disclose your PHI for the following purposes without obtaining your authorization.  And, with only limited exceptions, we will send all mail to you, the employee.  This includes mail relating to your spouse and other family members who are covered under the Plan.  If a person covered under the Plan has requested Restrictions or Confidential Communications, and if the Plan has agreed to the request, the Plan will send mail as provided by the request for Restrictions or Confidential Communications.  

Your Health Care Treatment:  The Plan may disclose your PHI for treatment (as defined in applicable federal rules) activities of a health care provider. 

Example:  If your doctor requested information from the Plan about previous claims under the Plan to assist in treating you, the Plan could disclose your PHI for that purpose. 

Example:  The Plan might disclose information about your prior prescriptions to a pharmacist for the pharmacist’s reference in determining whether a new prescription may be harmful to you. 

Making or Obtaining Payment for Health Care or Coverage:  The Plan may use or disclose your PHI for payment (as defined in applicable federal rules) activities, including making payment to or collecting payment from third parties, such as health care providers and other health plans. 

Example:  The Plan will receive bills from physicians for medical care provided to you that will contain your PHI.  The Plan will use this PHI, and create PHI about you, in the course of determining whether to pay, and paying, benefits with respect to such a bill.   

Example:  The Plan may consider and discuss your medical history with a health care provider to determine whether a particular treatment for which Plan benefits are or will be claimed is medically necessary as defined in the Plan. 

The Plan’s use or disclosure of your PHI for payment purposes may include uses and disclosures for the following purposes, among others. 

• Obtaining payments required for coverage under the Plan 
• Determining or fulfilling its responsibility to provide coverage and/or benefits under the Plan, including eligibility determinations and claims adjudication 
• Obtaining or providing reimbursement for the provision of health care (including coordination of benefits, subrogation, and determination of cost sharing amounts) 
• Claims management, collection activities, obtaining payment under a stop-loss insurance policy, and related health care data processing 
• Reviewing health care services to determine medical necessity, coverage under the Plan, appropriateness of care, or justification of charges 
• Utilization review activities, including precertification and preauthorization of services, concurrent and retrospective review of services 

 

The Plan also may disclose your PHI for purposes of assisting other health plans (including other health plans sponsored by the Company), health care providers, and health care clearinghouses with their payment activities, including activities like those listed above with respect to the Plan. 

Health Care Operations:  The Plan may use and disclose your PHI for health care operations (as defined in applicable federal rules) which includes a variety of facilitating activities. 

Example:  If claims you submit to the Plan indicate that you have diabetes or another chronic condition, the Plan may use and disclose your PHI to refer you to a disease management program.   

Example:  If claims you submit to the Plan indicate that the stop-loss coverage that the Company has purchased in connection with the Plan may be triggered, the Plan may use or disclose your PHI to inform the stop-loss carrier of the potential claim and to make any claim that ultimately applies. 

 

The Plan’s use and disclosure of your PHI for health care operations purposes may include uses and disclosures for the following purposes. 

• Quality assessment and improvement activities 
• Disease management, case management and care coordination 
• Activities designed to improve health or reduce health care costs 
• Contacting health care providers and patients with information about treatment alternatives  
• Accreditation, certification, licensing or credentialing activities  
• Fraud and abuse detection and compliance programs 

The Plan also may use or disclose your PHI for purposes of assisting other health plans (including other plans sponsored by the Company), health care providers and health care clearinghouses with their health care operations activities that are like those listed above, but only to the extent that both the Plan and the recipient of the disclosed information have a relationship with you and the PHI pertains to that relationship. 

• The Plan’s use and disclosure of your PHI for health care operations purposes may include uses and disclosures for the following additional purposes, among others. 
• Underwriting (with the exception of PHI that is genetic information) premium rating and performing related functions to create, renew or replace insurance related to the Plan 
• Planning and development, such as cost-management analyses 
• Conducting or arranging for medical review, legal services, and auditing functions 
• Business management and general administrative activities, including implementation of, and compliance with, applicable laws, and creating de-identified health information or a limited data set 

The Plan also may use or disclose your PHI for purposes of assisting other health plans for which the Company is the plan sponsor, and any insurers and/or HMOs with respect to those plans, with their health care operations activities similar to both categories listed above. 

Limited Data Set:  The Plan may disclose a limited data set to a recipient who agrees in writing that the recipient will protect the limited data set against inappropriate use or disclosure.  A limited data set is health information about you and/or others that omits your name and Social Security Number and certain other identifying information. 

Legally Required:  The Plan will use or disclose your PHI to the extent required to do so by applicable law.  This may include disclosing your PHI in compliance with a court order, or a subpoena or summons.  In addition, the Plan must allow the U.S. Department of Health and Human Services to audit Plan records. 

Health or Safety: When consistent with applicable law and standards of ethical conduct, the Plan may disclose your PHI if the Plan, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or the health and safety of others. The Plan can share health information about you for certain situations such as: 

• Preventing disease 
• Helping with product recalls 
• Reporting adverse reactions to medications 
• Reporting suspected abuse, neglect, or domestic violence 

 

Law Enforcement:  The Plan may disclose your PHI to a law enforcement official if the Plan believes in good faith that your PHI constitutes evidence of criminal conduct that occurred on the premises of the Plan.  The Plan also may disclose your PHI for limited law enforcement purposes. 

Lawsuits and Disputes:  In addition to disclosures required by law in response to court orders, the Plan may disclose your PHI in response to a subpoena, discovery request or other lawful process, but only if certain efforts have been made to notify you of the subpoena, discovery request or other lawful process or to obtain an order protecting the information to be disclosed. 

Workers’ Compensation:  The Plan may use and disclose your PHI when authorized by and to the extent necessary to comply with laws related to workers’ compensation or other similar programs. 

Emergency Situation:  The Plan may disclose your PHI to a family member, friend, or other person, for the purpose of helping you with your health care or payment for your health care, if you are in an emergency medical situation and you cannot give your agreement to the Plan to do this. 

Personal Representatives:  The Plan will disclose your PHI to your personal representatives appointed by you or designated by applicable law (a parent acting for a minor child, or a guardian appointed for an incapacitated adult, for example) to the same extent that the Plan would disclose that information to you.  The Plan may choose not to disclose information to a personal representative if it has reasonable belief that: 1) you have been or may be a victim of domestic abuse by your personal representative; or 2) recognizing such person as your personal representative may result in harm to you; or 3) it is not in your best interest to treat such person as your personal representative. 

Public Health: To the extent that other applicable law does not prohibit such disclosures, the Plan may disclose your PHI for purposes of certain public health activities, including, for example, reporting information related to an FDA-regulated product’s quality, safety or effectiveness to a person subject to FDA jurisdiction. 

Health Oversight Activities: The Plan may disclose your PHI to a public health oversight agency for authorized activities, including audits, civil, administrative or criminal investigations; inspections; licensure or disciplinary actions. 

Coroner, Medical Examiner, or Funeral Director:  The Plan may disclose your PHI to a coroner or medical examiner for the purposes of identifying a deceased person, determining a cause of death or other duties as authorized by law.  Also, the Plan may disclose your PHI to a funeral director, consistent with applicable law, as necessary to carry out the funeral director’s duties. 

Organ Donation:  The Plan may use or disclose your PHI to assist entities engaged in the procurement, banking, or transplantation of cadaver organs, eyes, or tissue. 

Specified Government Functions:  In specified circumstances, federal regulations may require the Plan to use or disclose your PHI to facilitate specified government functions related to the military and veterans, national security and intelligence activities, protective services for the president and others, and correctional institutions and inmates. 

Research:  The Plan may disclose your PHI to researchers when your individual identifiers have been removed or when an institutional review board or privacy board has reviewed the research proposal and established a process to ensure the privacy of the requested information and approves the research. 

Disclosures to You:  When you make a request for your PHI, the Plan is required to disclose to you your medical records, billing records, and any other records used to make decisions regarding your health care benefits.  The Plan must also, when requested by you, provide you with an accounting of disclosures of your PHI if such disclosures were for any reason other than Treatment, Payment, or Health Care Operations (and if you did not authorize the disclosure). 

Authorization to Use or Disclose Your PHI 

Except as stated above, the Plan will not use or disclose your PHI unless it first receives written authorization from you.  If you authorize the Plan to use or disclose your PHI, you may revoke that authorization in writing at any time, by sending notice of your revocation to the contact person named at the end of this Notice.  To the extent that the Plan has taken action in reliance on your authorization (entered into an agreement to provide your PHI to a third party, for example) you cannot revoke your authorization. 

Furthermore, we will not: (1) supply confidential information to another company for its marketing purposes (unless it is for certain limited Health Care Operations); (2) sell your confidential information (unless under strict legal restrictions) (to sell means to receive direct or indirect remuneration); (3) provide your confidential information to a potential employer with whom you are seeking employment without your signed authorization; or (4) use or disclose psychotherapy notes unless required by law. 

Additionally, if a state or other law requires disclosure of immunization records to a school, written authorization is no longer required.  However, a covered entity still must obtain and document an agreement which may be oral and over the phone.    

The Plan May Contact You 

The Plan may contact you for various reasons, usually in connection with claims and payments and usually by mail. 

You should note that the Plan may contact you about treatment alternatives or other health-related benefits and services that may be of interest to you. 

Your Rights With Respect to Your PHI 

Confidential Communication by Alternative Means:  If you feel that disclosure of your PHI could endanger you, the Plan will accommodate a reasonable request to communicate with you by alternative means or at alternative locations.  For example, you might request the Plan to communicate with you only at a particular address.  If you wish to request confidential communications, you must make your request in writing to the contact person named at the end of this Notice.  You do not need to state the specific reason that you feel disclosure of your PHI might endanger you in making the request, but you do need to state whether that is the case.  Your request also must specify how or where you wish to be contacted.  The Plan will notify you if it agrees to your request for confidential communication.  You should not assume that the Plan has accepted your request until the Plan confirms its agreement to that request in writing. 

Request Restriction on Certain Uses and Disclosures:  You may request the Plan to restrict the uses and disclosures it makes of your PHI.  This request will restrict or limit the PHI that is disclosed for Treatment, Payment, or Health Care Operations, and this restriction may limit the information that the Plan discloses to someone who is involved in your care or the payment for your care.  The Plan is not required to agree to a requested restriction, but if it does agree to your requested restriction, the Plan is bound by that agreement, unless the information is needed in an emergency situation.  There are some restrictions, however, that are not permitted even with the Plan’s agreement.  To request a restriction, please submit your written request to the contact person identified at the end of this Notice.  In the request please specify:  (1) what information you want to restrict; (2) whether you want to limit the Plan’s use of that information, its disclosure of that information, or both; and (3) to whom you want the limits to apply (a particular physician, for example).  The Plan will notify you if it agrees to a requested restriction on how your PHI is used or disclosed.  You should not assume that the Plan has accepted a requested restriction until the Plan confirms its agreement to that restriction in writing. You may request restrictions on our use and disclosure of your confidential information for the treatment, payment and health care operations purposes explained in this Notice.  Notwithstanding this policy, the plan will comply with any restriction request if (1) except as otherwise required by law, the disclosure is to the health plan for purposes of carrying out payment or health care operations (and it is not for purposes of carrying out treatment); and (2) the PHI pertains solely to a health care item or service for which the health care provider has been paid out-of-pocket in full. 

Right to Be Notified of a Breach:  You have the right to be notified in the event that the plan (or a Business Associate) discovers a breach of unsecured protected health information. 

Electronic Health Records:  You may also request and receive an accounting of disclosures of electronic health records made for treatment, payment, or health care operations during the prior three years for disclosures made on or after (1) January 1, 2014 for electronic health records acquired before January 1, 2009; or (2) January 1, 2011 for electronic health records acquired on or after January 1, 2009.   

The first list you request within a 12-month period will be free.  You may be charged for providing any additional lists within a 12-month period. 

Paper Copy of This Notice:  You have a right to request and receive a paper copy of this Notice at any time, even if you received this Notice previously, or have agreed to receive this Notice electronically.  To obtain a paper copy please call or write the contact person named at the end of this Notice. 

Right to Access Your PHI:  You have a right to access your PHI in the Plan’s enrollment, payment, claims adjudication and case management records, or in other records used by the Plan to make decisions about you, in order to inspect it and obtain a copy of it.  Your request for access to this PHI should be made in writing to the contact person named at the end of this Notice.  The Plan may deny your request for access, for example, if you request information compiled in anticipation of a legal proceeding.  If access is denied, you will be provided with a written notice of the denial, a description of how you may exercise any review rights you might have, and a description of how you may complain to Plan or the Secretary of Health and Human Services.  If you request a copy of your PHI, the Plan may charge a reasonable fee for copying and, if applicable, postage associated with your request. 

Right to Amend:  You have the right to request amendments to your PHI in the Plan’s records if you believe that it is incomplete or inaccurate.  A request for amendment of PHI in the Plan’s records should be made in writing to the contact person named at the end of this Notice.  The Plan may deny the request if it does not include a reason to support the amendment.  The request also may be denied if, for example, your PHI in the Plan’s records was not created by the Plan, if the PHI you are requesting to amend is not part of the Plan's records, or if the Plan determines the records containing your health information are accurate and complete.  If the Plan denies your request for an amendment to your PHI, it will notify you of its decision in writing, providing the basis for the denial, information about how you can include information on your requested amendment in the Plan’s records, and a description of how you may complain to Plan or the Secretary of Health and Human Services. 

Accounting: You have the right to receive an accounting of certain disclosures made of your health information. Most of the disclosures that the Plan makes of your PHI are not subject to this accounting requirement because routine disclosures (those related to payment of your claims, for example) generally are excluded from this requirement. Also, disclosures that you authorize, or that occurred more than six years before the date of your request, are not subject to this requirement. To request an accounting of disclosures of your PHI, you must submit your request in writing to the contact person named at the end of this Notice. Your request must state a time period which may not include dates more than six years before the date of your request. Your request should indicate in what form you want the accounting to be provided (for example on paper or electronically). The first list you request within a 12-month period will be free. If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting. 

 

Personal Representatives:  You may exercise your rights through a personal representative.  Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you.  The Plan retains discretion to deny a personal representative access to your PHI to the extent permissible under applicable law. 

Complaints 

If you believe that your privacy rights have been violated, you have the right to express complaints to the Plan and to the Secretary of the Department of Health and Human Services.  Any complaints to the Plan should be made in writing to the contact person named at the end of this Notice.  The Plan encourages you to express any concerns you may have regarding the privacy of your information.  You will not be retaliated against in any way for filing a complaint. 

Contact Information 

The Plan has designated Daniel Arnold, Director of Business Services, as its contact person for all issues regarding the Plan’s privacy practices and your privacy rights.  You can reach him at:  901 15^th Avenue, South Milwaukee, WI 53172, phone 414-766-5027, fax 414-766-5029, email darnold@sdsm.k12.wi.us

 

PDF: WHCRA Notice 2024-25

WOMEN’S HEALTH AND CANCER RIGHTS ACT

If you have had a mastectomy or expect to have one, you may be entitled to special rights under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). The following questions and answers clarify your basic WHCRA rights.

I’ve been diagnosed with breast cancer and plan to have a mastectomy, which my plan covers. Will my health plan cover reconstructive surgery too?

• If your group health plan or health insurance company covers mastectomies, it must provide certain reconstructive surgery and other benefits related to the mastectomy, including: YOUR RIGHTS AFTER A MASTECTOMY EMPLOYEE BENEFITS SECURITY ADMINISTRATION UNITED STATES DEPARTMENT OF LABOR
• all stages of reconstruction of the breast on which the mastectomy was performed,
• surgery and reconstruction of the other breast to produce a symmetrical appearance,
• prostheses, and
• treatment of physical complications of the mastectomy, including lymphedema.

The plan must consult with you and your attending physician when determining how this coverage will be provided.

I must have a mastectomy for medical reasons, although I have not been diagnosed with cancer. Does WHCRA apply to me?

Yes, the law applies if your group health plan or health insurance company covers mastectomies and you are receiving benefits in connection with a mastectomy – whether or not you have cancer. Despite its name, nothing in the law limits WHCRA rights to cancer patients. Do all group health plans and health insurance companies have to provide reconstructive surgery benefits? Generally, WHCRA applies to all group health plans that provide coverage for medical and surgical benefits with respect to a mastectomy, as well as their insurance companies. However, there are exceptions for some “church plans” and “government plans.” If your coverage is provided by a “church plan” or “governmental plan,” check with your plan administrator.

Will I have to pay a deductible or coinsurance? 

Possibly. Group health plans or health insurance companies may impose deductibles or coinsurance requirements on mastectomies and post-mastectomy treatment, but no more than those established for other benefits. In other words, the deductible for post-mastectomy reconstructive surgery should be similar to the deductible for any similar procedure covered by the plan.

Before I changed jobs, I had a mastectomy and chemotherapy which were covered under my previous employer’s plan. Now I am enrolled under my new employer’s plan and want reconstructive surgery. Is my new employer’s plan required to cover it? 

If you request reconstructive surgery, your new employer’s plan generally must cover it if:

• the plan provides coverage for mastectomies, and
• you are receiving benefits under the plan that are related to your mastectomy.
• In addition, your new employer’s plan generally must cover the other benefits specified in WHCRA, even if you were not enrolled in your new employer’s plan when you had the mastectomy. The Patient Protection and Affordable Care Act includes additional protections. A group health plan generally cannot limit or deny benefits relating to a health condition that existed before you enrolled in your new employer’s plan. For more information, visit dol.gov/ agencies/ebsa/laws-and-regulations/ laws/affordable-care-act/for-workers-andfamilies or HealthCare.gov.

My employer’s group health plan provides coverage through an insurance company. After my mastectomy, my employer changed insurance companies. The new insurance company refuses to cover my reconstructive surgery. Is that legal?

Not if:

• the new insurance company provides coverage for mastectomies,
• you are receiving benefits under the plan related to your mastectomy, and
• you elect to have reconstructive surgery.

If these conditions apply, then the new insurance company must provide coverage for breast reconstruction as well as the other benefits required under WHCRA. It does not matter that you were not covered by the new company when you had the mastectomy.

I understand that my group health plan must provide me with a notice of my WHCRA rights when I enroll in the plan. What information does this notice include?

Plans must provide a notice to all employees when they enroll in the health plan that:

• describes the benefits that WHCRA requires the plan and its insurance companies to cover, which includes:
  • coverage of all stages of reconstruction of the breast on which the mastectomy was performed,
  • surgery and reconstruction of the other breast to produce a symmetrical appearance,
  • prostheses, and
  • treatment of physical complications of the mastectomy, including lymphedema;
• states that mastectomy-related benefits coverage will be provided in a manner determined in consultation with the attending physician and the patient;
• describes any applicable deductibles and coinsurance limitations that apply to the coverage specified under WHCRA. Deductibles and coinsurance limitations may be imposed only if they are consistent with those established for other benefits under the plan or coverage.

What information does the annual WHCRA notice from my health plan include?

Your annual notice should describe the four categories of coverage required under WHCRA and how to obtain a detailed description of the mastectomy-related benefits available under your plan. For example, an annual notice might look like this: “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 your plan administrator [phone number here] for more information.” Your annual notice may be the same notice provided when you enrolled in the plan if it contains the information described above.

My state also requires health insurance companies to cover minimum hospital stays in connection with a mastectomy (which is not required by WHCRA). If I have a mastectomy and breast reconstruction, am I also entitled to the minimum hospital stay? If your employer’s group health plan provides coverage through an insurance company, you are entitled to the minimum hospital stay required by the state law. Many state laws provide more protections than WHCRA for coverage provided by an insurance company or “insured coverage.”

If your employer’s group health plan provides…	You are entitled to…
Coverage through an insurance company	Federal and state protections (in states that provide them)
Self-insured coverage	Federal protections only

To find out if your group health coverage is “insured” or “self-insured,” check your health plan’s Summary Plan Description (SPD) or contact your plan administrator. If your coverage is “insured” and you want to know if you have additional state law protections, contact your state insurance department.

I have health coverage through an individual policy, not through an employer. Am I covered under WHCRA? 

WHCRA rights apply to individual coverage as well. These requirements are generally within the jurisdiction of the state insurance department. Call your state insurance department or the Department of Health and Human Services toll free at 1-877-267-2323, extension 6-1565, for more information.

Can I get breast cancer screening or similar preventive services for free?

Possibly. Under the Affordable Care Act, you may receive certain recommended preventive services, such as breast cancer mammography screenings for women aged 40 and older, with no copayment, coinsurance, deductible, or other cost-sharing. For more information, visit HealthCare.gov/coverage/preventive-carebenefits/. WHCRA does not require coverage for preventive services related to the detection of breast cancer.

Resources

HCRA is administered by the U.S. Departments of Labor and Health and Human Services.

Department of Labor For more information about your WHCRA rights under an employer-sponsored group health plan and other health coverage topics, visit dol.gov/agencies/ebsa. To order publications, learn more about our programs and services, or discuss questions about your benefits, contact EBSA at askebsa.dol.gov or call toll-free: 1-866444-3272.

Department of Health and Human Services For more information on WHCRA, visit    www.cms.gov/CCIIO/Programs-andInitiatives/Other-Insurance-Protections/ whcra_factsheet.html or call toll-free: 1-877-267-2323, extension 6-1565.

National Association of Insurance Commissioners To find the contact information for your state office, visit naic.org/state_web_map. htm.

PDF: WHCRA Notice 2024-25

PDF: Childrens Health Insurance Program-CHIP 2024-25

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, 2023. Contact your State for more information on  eligibility – 

GEORGIA – Medicaid	INDIANA – Medicaid
GA HIPP Website: https://medicaid.georgia.gov/health insurance-premium-payment-program-hipp  Phone: 678-564-1162, Press 1  GA CHIPRA Website:   https://medicaid.georgia.gov/programs/third-party liability/childrens-health-insurance-program-reauthorization act-2009-chipra  Phone: 678-564-1162, Press 2	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)	KANSAS – Medicaid
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	Website: https://www.kancare.ks.gov/  Phone: 1-800-792-4884   HIPP Phone: 1-800-967-4660
KENTUCKY – Medicaid	LOUISIANA – 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/agencies/dms	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	MASSACHUSETTS – Medicaid and CHIP
Enrollment Website:   https://www.mymaineconnection.gov/benefits/s/?language=en _US  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	Website: https://www.mass.gov/masshealth/pa   Phone: 1-800-862-4840   TTY: 711  Email: masspremassistance@accenture.com
MINNESOTA – Medicaid	MISSOURI – 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	Website:   http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
MONTANA – Medicaid	NEBRASKA – Medicaid
Website:   http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084  Email: HHSHIPPProgram@mt.gov	Website: http://www.ACCESSNebraska.ne.gov  Phone: 1-855-632-7633  Lincoln: 402-473-7000  Omaha: 402-595-1178

 

NEVADA – Medicaid	NEW HAMPSHIRE – Medicaid
Medicaid Website: http://dhcfp.nv.gov  Medicaid Phone: 1-800-992-0900	Website: https://www.dhhs.nh.gov/programs  services/medicaid/health-insurance-premium-program Phone: 603-271-5218  Toll free number for the HIPP program: 1-800-852-3345, ext.  5218
NEW JERSEY – Medicaid and CHIP	NEW YORK – Medicaid
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	Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
NORTH CAROLINA – Medicaid	NORTH DAKOTA – Medicaid
Website: https://medicaid.ncdhhs.gov/  Phone: 919-855-4100	Website: https://www.hhs.nd.gov/healthcare  Phone: 1-844-854-4825
OKLAHOMA – Medicaid and CHIP	OREGON – Medicaid
Website: http://www.insureoklahoma.org  Phone: 1-888-365-3742	Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid and CHIP	RHODE ISLAND – Medicaid and CHIP
Website:   https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP Program.aspx  Phone: 1-800-692-7462  CHIP Website: Children's Health Insurance Program (CHIP)  (pa.gov)  CHIP Phone: 1-800-986-KIDS (5437)	Website: http://www.eohhs.ri.gov/  Phone: 1-855-697-4347, or   401-462-0311 (Direct RIte Share Line)
SOUTH CAROLINA – Medicaid	SOUTH DAKOTA - Medicaid
Website: https://www.scdhhs.gov  Phone: 1-888-549-0820	Website: http://dss.sd.gov  Phone: 1-888-828-0059
TEXAS – Medicaid	UTAH – Medicaid and CHIP
Website: Health Insurance Premium Payment (HIPP)  Program | Texas Health and Human Services  Phone: 1-800-440-0493	Medicaid Website: https://medicaid.utah.gov/  CHIP Website: http://health.utah.gov/chip  Phone: 1-877-543-7669
VERMONT– Medicaid	VIRGINIA – Medicaid and CHIP
Website: Health Insurance Premium Payment (HIPP) Program  | Department of Vermont Health Access  Phone: 1-800-250-8427	Website: https://coverva.dmas.virginia.gov/learn/premium assistance/famis-select   https://coverva.dmas.virginia.gov/learn/premium assistance/health-insurance-premium-payment-hipp-programs  Medicaid/CHIP Phone: 1-800-432-5924
WASHINGTON – Medicaid	WEST VIRGINIA – Medicaid and CHIP
Website: https://www.hca.wa.gov/   Phone: 1-800-562-3022	Website: https://dhhr.wv.gov/bms/   http://mywvhipp.com/  Medicaid Phone: 304-558-1700  CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

 

WISCONSIN – Medicaid and CHIP	WYOMING – Medicaid
Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002	Website:   https://health.wyo.gov/healthcarefin/medicaid/programs-and eligibility/  Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2023, 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) 

Paperwork Reduction Act Statement 

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 

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 collection of information,  including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office  of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or  email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.  

OMB Control Number 1210-0137 (expires 1/31/2026) 

PDF: Childrens Health Insurance Program-CHIP 2024-25

PDF: 2024-25 Marketplace Options

PART A: General Information

Even if you are offered health coverage through your employment, you may have other coverage options through the Health Insurance Marketplace (“Marketplace”).To assist you as you evaluate options for you and your family, this notice provides some basic information about the Health Insurance Marketplace. 

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options in your geographic area. 

Can I Save Money on my Health Insurance Premiums in the Marketplace? 

You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer does not offer coverage, or offers coverage that is not considered affordable for you and doesn’t meet certain minimum value standards (discussed below). The savings on your premium that you're eligible for depends on your household income. You may also be eligible for a tax credit that lowers your costs. 

Does Employment-Based Health Coverage Affect Eligibility for Premium Savings through the Marketplace? 

Yes. If you have an offer of health coverage from your employer that is considered affordable for you and meets certain minimum value standards, you will not be eligible for a tax credit, or advance payment of the tax credit, for your Marketplace coverage and may wish to enroll in your employment-based health plan. However, you may be eligible for a tax credit, and advance payments of the credit, that lowers your monthly premium, or a reduction in certain cost-sharing, if your employer does not offer coverage to you at all or does not offer coverage that is considered affordable for you or meet minimum value standards. If your share of the premium cost of all plans offered to you through your employment is more than 9.12%1 of your annual household income, or if the coverage through your employment does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit, and advance payment of the credit, if you do not enroll in the employment-based health coverage. For family members of the employee, coverage is considered affordable if the employee’s cost of premiums for the lowest-cost plan that would cover all family members does not exceed 9.12% of the employee’s household income..12

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered through your employment, then you may lose access to whatever the employer contributes to the employment-based coverage. Also, this employer contribution -as well as your employee contribution to employment-based coverage- is generally excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. In addition, note that if the health coverage offered through your employment does not meet the affordability or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You should consider all of these factors in determining whether to purchase a health plan through the Marketplace. 

When Can I Enroll in Health Insurance Coverage through the Marketplace? 

You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period. Open Enrollment varies by state but generally starts November 1 and continues through at least December 15. Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment Period. In general, you qualify for a Special Enrollment Period if you’ve had certain qualifying life events, such as getting married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the qualifying life event to enroll in a Marketplace plan.

There is also a Marketplace Special Enrollment Period for individuals and their families who lose eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage on or after March 31, 2023, through July 31, 2024. Since the onset of the nationwide COVID-19 public health emergency, state Medicaid and CHIP agencies generally have not terminated the enrollment of any Medicaid or CHIP beneficiary who was enrolled on or after March 18, 2020, through March 31, 2023. As state Medicaid and CHIP agencies resume regular eligibility and enrollment practices, many individuals may no longer be eligible for Medicaid or CHIP coverage starting as early as March 31, 2023. The U.S. Department of Health and Human Services is offering a temporary Marketplace Special Enrollment period to allow these individuals to enroll in Marketplace coverage.

Marketplace-eligible individuals who live in states served by HealthCare.gov and either- submit a new application or update an existing application on HealthCare.gov between March 31, 2023 and July 31, 2024, and attest to a termination date of Medicaid or CHIP coverage within the same time period, are eligible for a 60-day Special Enrollment Period. That means that if you lose Medicaid or CHIP coverage between March 31, 2023, and July 31, 2024, you may be able to enroll in Marketplace coverage within 60 days of when you lost Medicaid or CHIP coverage.  In addition, if you or your family members are enrolled in Medicaid or CHIP coverage, it is important to make sure that your contact information is up to date to make sure you get any information about changes to your eligibility. To learn more, visit HealthCare.gov or call the Marketplace Call Center at 1-800318-2596. TTY users can call 1-855-889-4325. 

What about Alternatives to Marketplace Health Insurance Coverage? 

If you or your family are eligible for coverage in an employment-based health plan (such as an employer-sponsored health plan), you or your family may also be eligible for a Special Enrollment Period to enroll in that health plan in certain circumstances, including if you or your dependents were enrolled in Medicaid or CHIP coverage and lost that coverage. Generally, you have 60 days after the loss of Medicaid or CHIP coverage to enroll in an employment-based health plan, but if you and your family lost eligibility for Medicaid or CHIP coverage between March 31, 2023 and July 10, 2023, you can request this special enrollment in the employment-based health plan through September 8, 2023. Confirm the deadline with your employer or your employment based health plan. Alternatively, you can enroll in Medicaid or CHIP coverage at any time by filling out an application through the Marketplace or applying directly through your state Medicaid  agency. Visit https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/ for more details. 

How Can I Get More Information? 

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. 

PART B: Information About Health Coverage Offered by Your Employer 

This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

See Form

You are not eligible for health insurance coverage through this employer. You and your family may be able to obtain health coverage through the Marketplace, with a new kind of tax credit that lowers your monthly premiums and with assistance for out-of-pocket costs. 

PDF: 2024-25 Marketplace Options