Important Notices & Disclosures

About COBRA Coverage

General Notice of COBRA Continuation Coverage Rights
INTRODUCTION: You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. This notice does not fully describe COBRA continuation coverage or other rights under the plan. For additional and more complete information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse or domestic partner, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage may be required to pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary entitled to elect COBRA continuation coverage if you lose your coverage under the Plan because either one of the following qualifying events happens:

• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.

If you are the spouse or domestic partner of an employee, you will become a qualified beneficiary entitled to elect COBRA continuation coverage if you lose your coverage under the Plan because any of the following qualifying events happens:

• Your spouse or domestic partner dies;
• Your spouse or domestic partner’s hours of employment are reduced;
• Your spouse or domestic partner’s employment ends for any reason other than his or her gross misconduct;
• Your spouse or domestic partner becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse or domestic partner. In the event your spouse, who is the employee, reduces or terminates your coverage under the Plan in anticipation of a divorce or legal separation which later occurs, the divorce or legal separation may be considered a qualifying event even though the coverage was reduced or terminated before the divorce or separation.

Your dependent children, including any child born to or placed for adoption with a covered employee during the period of COBRA coverage who is thereafter properly enrolled in the Plan, or a child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order, will become qualified beneficiaries entitled to elect COBRA continuation coverage if they lose coverage under the Plan because any of the following qualifying events happens:

• The parent-employee dies;
• The parent-employee’s hours of employment are reduced;
• The parent-employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the plan as a "dependent child."

When is Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or the employee is becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.

You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the employee and spouse or domestic partner or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator in writing within 60 days after the qualifying event occurs.

How is COBRA Coverage Provided?

Once the Plan Administrator receives timely notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, domestic partners and parents may elect COBRA continuation coverage on behalf of their children. If COBRA continuation coverage is not elected within the 60-day election period, a qualified beneficiary will lose the right to elect COBRA continuation coverage. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage may last for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse or domestic partner and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended.

Disability Extension of 18 Month Period of Continuation Coverage

If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. The Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period and within 18 months after the covered employee’s termination of employment or reduction of hours, there will be no disability extension of COBRA continuation coverage. The affected individual must also notify the Plan Administrator within 30 days of any final determination that the individual is no longer disabled.

Second Qualifying Event Extension of 18 Month Period of Continuation Coverage

If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse or domestic partner and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse or domestic partner and any dependent children receiving COBRA continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or domestic partner or dependent child to lose coverage under the Plan had the first qualifying event not occurred. The Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period, there will be no extension of COBRA continuation coverage due to a second qualifying event.

If You Have Questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)

Keep Your Plan Informed of Address Changes

In order to protect your family’s rights, you should keep the Plan Administrator informed of the current addresses and of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Machine Readable Files

Machine Readable Files (MRFs) can be accessed at https://www.cigna.com/legal/compliance/machine-readable-files.

This link leads to the machine-readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated service rates and out-of-network allowed amounts between health plans and healthcare providers. The machine readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

Plan Contact Information

Michael Sullivan & Associates Human Resources Department: 805-796-0839.

Women’s Health and Cancer Rights Act of 1998
In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits:

• 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; and
• Prostheses and treatment of physical complications of the mastectomy, including lymphedema.

Health plans must provide coverage of mastectomy-related benefits in a manner determined in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under this plan.

Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse or domestic partner) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after you or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact the Human Resources Department.

Privacy Notice
Michael Sullivan & Associates Health and Welfare Plan has issued a Health Plan Privacy Notice that describes how the Plan uses and discloses protected health information (PHI). You can obtain a copy of the Michael Sullivan & Associates Health and Welfare Plan Privacy Notice upon your written request to the Human Resources Department. If you have any questions, please contact the Human Resources Department.

Mothers’ Health Protection Act Disclosure
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96).

USERRA Health Insurance Protection
If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. Even if you don’t elect to continue coverage during your military service, you have the right to be reinstated in your employer’s health plan when you are reemployed, generally without any waiting periods or exclusions except for service-connected illness or injuries.

Adult Child Age Requirement

Children up to the age of 26 will now be allowed to enroll in the Michael Sullivan & Associates Medical benefit plan.

Lifetime Limit

The lifetime limit on the dollar value of benefits under the Michael Sullivan & Associates Health Plans no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment.

Pre-Tax Benefits Deductions

Your share of the cost of health care coverage is paid with pre-tax dollars. This means that Michael Sullivan & Associates reduces your pay by the amount of your payments—before Federal income taxes, State income taxes and Social Security taxes are calculated. Under current income tax rules, this lowers your income for tax purposes.

Availability of Summary Health Information

As an employee, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in case of injury or illness. Your plan offers a series of health coverage options. Choosing a health plan is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options. The SBC is available on the web at www.michaelsullivanbenefits.com. A paper copy is also available, free of charge, by calling Human Resources at 805-796-0839

How is COBRA Coverage Provided?

Once the Plan Administrator receives timely notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, domestic partners and parents may elect COBRA continuation coverage on behalf of their children. If COBRA continuation coverage is not elected within the 60-day election period, a qualified beneficiary will lose the right to elect COBRA continuation coverage. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage may last for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse or domestic partner and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended.

Designation of Primary Physicians

Michael Sullivan & Associates generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members until you make this designation, Michael Sullivan & Associates / Group Health Plan designates one for you. For women, an OB/GYN may be designated as the Primacy Care Physician. For information on how to select a primary care provider, contact the ORION Benefits Helpline at 855- 343-8883. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from Michael Sullivan & Associates or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.

Grandfathered Health Plans

Michael Sullivan & Associates health plan believes this plan is a “non-grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). You may contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform to obtain more information. This website has a table summarizing which protections do and do not apply to grandfathered health plans.

Among Specific Protections, Health Insurance Portability and Accountability Act (HIPAA):

In short, HIPAA may lower your chance of losing existing coverage, ease your ability to switch health plans and/or help you buy coverage on your own if you lose your employer's plan and have no other coverage available.

HIPAA Privacy: The HIPAA Privacy Rule is effective April 14, 2003. The Privacy Rule is intended to safeguard protected health information (PHI) created and held by health care providers, health plans, health information clearing houses and their business associates. The provisions of the Privacy Rule have a significant impact on those who deal with health information and on all citizens with regard to their personal PHI.ORION, our health insurance broker and all of our contracted plans adhere to the HIPAA Privacy Rule.

Genetic Information Nondiscrimination Act

GINA (Genetic Information Nondiscrimination Act of 2008, effective 1-1-10) prohibits group health plans from collecting genetic information and discriminating in enrollment and cost of coverage based on an individual’s genetic information – which includes family medical information. The Plan may not request or require an individual to undergo genetic tests, and it is prohibited from collecting genetic information (including family medical history) prior to or in connection with enrollment, or for underwriting purposes.

Working Families Tax Relief Act (WFTRA)

The Working Families Tax Relief Act of 2004 (WFTRA) changed the rules under Internal Revenue Code Section 152 for determining who you can cover tax free under certain employee benefit plans. The rules took effect January 1, 2005. The rules define two types of dependents, "Qualifying Children" and “Qualifying Relatives."

• A “Qualifying Child” is your child, or a brother, sister, stepbrother, stepsister or descendant of any such relative who lives with you for over half of the year, does not provide over half of his/her own support and is under age 19 as of the close of the calendar year (or under age 24 as of the close of the calendar year and a full-time student) or is permanently and totally disabled. If a person is a "Qualifying Child" of one taxpayer, the person cannot be a "Qualifying Relative" of another.
• A "Qualifying Relative" is a person that doesn’t meet the definition of a “Qualifying Child” for any taxpayer, receives more than half of his/her support from you, and is either your relative (generally a relative will include your parent, grandparent, stepparent, child, grandchild, brother, sister, stepbrother, stepsister, aunt or uncle, niece or nephew, or your spouse or domestic partner’s parents, brother, sister or children) or an individual that has the same principle place of abode as you and is a member of your household for the entire taxable year.

This change may impact your family's entitlement to employee benefits, may change the tax treatment for some benefit coverage, and may eliminate reimbursement of expenses under a healthcare flexible spending account. The rule also does not allow you to receive dependent care reimbursement for a child under 13 years of age unless that child is your "Qualifying Child."

If your dependent child does not meet the definition of Qualifying Child or Qualifying Relative, the portion paid by the employer and the portion paid by the employee on a pre-tax-basis will result in imputed income to you based on the Fair Market Value of the coverage. NOTE: Even though the IRS definition of Qualifying Child is to age 19 and to age 24 if full time student, if the child reaches 19 or 24 during the calendar year, the child is considered over the age limit for the entire year, resulting in imputed income for the year unless the child qualifies as a "Qualifying Relative."

Our health plan extends coverage to children to age 26. We recommend that you consult your tax adviser to determine which of your family members will qualify as your dependent under the IRS rules.

If your dependent child(ren) meet the IRS definition of Qualifying Child or Qualifying Relative and that changes, you must notify HR immediately.

The information provided should not be construed as legal or tax advice. The contents are intended for general information purposes only and you are urged to consult an attorney or tax advisor concerning your own situation and any specific questions you may have.

Medicare Credible Coverage

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

• 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.
• Your Employer has determined that the prescription drug coverage offered by Kaiser 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.

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

If you decide to join a Medicare drug plan, your current coverage will not be affected. Your current prescription drug coverage available to you through your employer-sponsored health plans.

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

You should also know that if you drop or lose your current coverage with your Employer 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 prescription drug 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 November to join.

For additional information please contact:
www.medicare.gov or call your State Health Insurance Assistance Program at 1-800-633-4227 for personalized help.

Medicaid and the Children's Health Insurance Program (CHIP)
Offer Free or Low-Cost Health Coverage to Children and Families

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:

Alabama - Medicaid	New York - Medicaid
Website: http://myalhipp.com/ Phone: 1-855-692-5447	Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831
Alaska - Medicaid	New Jersey - Medicaid and CHIP
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	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
Arkansas - Medicaid	North Carolina - Medicaid
Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)	Website: https://dma.ncdhhs.gov/ Phone: 919-855-4100
Colorado - Health First Colorado & Child Health Plan Plus	Indiana - Medicaid
Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711	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: http://www.indianamedicaid.com Phone 1-800-403-0864
Florida - Medicaid	Oklahoma - Medicaid and CHIP
Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268	Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
Georgia - Medicaid	Oregon - Medicaid
Website: http://dch.georgia.gov/medicaid - Click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507	Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075
North Dakota - Medicaid	Pennsylvania - Medicaid
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825	Website: http://www.dhs.pa.gov/provider/medicalassistance/ healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462
Nebraska - Medicaid	Virginia - Medicaid and CHIP
Website: http://www.ACCESSNebraska.ne.gov Phone: (855) 632-7633 Lincoln: (402) 473-7000 Omaha: (402) 595-1178	Medicaid Website: http://www.coverva.org/ programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/ programs_premium_assistance.cfm
Iowa - Medicaid	South Carolina - Medicaid
Website: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp Phone: 1-888-346-9562	Website: http://www.scdhhs.gov Phone: 1-888-549-0820
Kansas - Medicaid	South Dakota - Medicaid
Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512	Website: http://dss.sd.gov Phone: 1-888-828-0059
Kentucky - Medicaid	Texas - Medicaid
Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570	Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493
Louisiana - Medicaid	Utah - Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447	Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669
Maine - Medicaid	Vermont - Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711	Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
Massachusetts - Medicaid and CHIP	Rhode Island - Medicaid
Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840	Website: http://www.eohhs.ri.gov/ Phone: 855-697-4347
Minnesota - Medicaid	Washington - Medicaid
Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/ health-care-programs/programs-and-services/medical-assistance.jsp Phone: 1-800-657-3739	Website: http://www.hca.wa.gov/free-or-low-cost-health-care/programadministration/ premium-payment-program Phone: 1-800-562-3022 ext. 15473
Missouri - Medicaid	West Virginia - Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005	Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
Nevada - Medicaid	Wisconsin - Medicaid
Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900	Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002
New Hampshire - Medicaid	Wyoming - Medicaid
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218	Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
Montana - Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact:

IMPORTANT NOTICE FROM MICHAEL SULLIVAN & ASSOCIATES, LLP 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 MICHAEL SULLIVAN & ASSOCIATES, LLP 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:

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.

MICHAEL SULLIVAN & ASSOCIATES, LLP HAS DETERMINED THAT THE PRESCRIPTION DRUG COVERAGE OFFERED BY THE MICHAEL SULLIVAN & ASSOCIATES, LLP EMPLOYEE BENEFIT 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 Michael Sullivan & Associates, LLP coverage will not be affected. An outline of your current prescription drug coverage follows:

• Cigna HMO 250 Rx $10/$20/$40
• Cigna OA Plus PPO 250 Rx $10/$20/$40
• Kaiser HMO Rx $15/$35/$35

If you do decide to join a Medicare drug plan and drop your current Michael Sullivan & Associates, LLP coverage, be aware that you and your dependents will 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 Michael Sullivan & Associates, LLP 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 Michael Sullivan & Associates, LLP 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:	October 12, 2020
Name of Entity/Sender:	Michael Sullivan & Associates, LLP
Contact-Position/Office:	Human Resources
Address:	1440 Harbor Blvd. #500, Fullerton, CA 92835
Phone Number:	(714) 202-3440