Page 17 - Quarles

Important Notices 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
Copies of the Quarles Petroleum, Inc. Summary Plan eligible for health coverage from your employer, your
Descriptions (SPDs) are available from Human state may have a premium assistance program that can
Resources. help pay for coverage, using funds from their Medicaid or

Notice of Special Enrollment Rights for Health Plan CHIP programs. If you or your children aren’t eligible for
Coverage Medicaid or CHIP, you won’t be eligible for these
If you have declined enrollment in a Quarles Petroleum, premium assistance programs but you may be able to
Inc. health plan for you or your dependents (including buy individual insurance coverage through the Health
your spouse) because of other health insurance Insurance Marketplace. For more information, visit
coverage, you or your dependents may be able to enroll healthcare.gov.

in some coverages under this plan without waiting for the
next open enrollment period, provided that you request If you or your dependents are already enrolled in
enrollment within 31 days after your other coverage ends. Medicaid or CHIP, contact your state’s Medicaid or CHIP

office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in
Health Insurance Portability and Accountability Act Medicaid or CHIP, and you think you or any of your
of 1996 (HIPAA): Under the HIPAA privacy dependents might be eligible for either of these
regulations, the Quarles Petroleum, Inc. health plans are programs, contact your State Medicaid or CHIP office or
required to protect the privacy and security of your dial 877-KIDS NOW or go to insurekidsnow.gov to find
protected health information. A copy of the Plan’s Notice out how to apply. If you qualify, ask your state if it has a
of Privacy Practices is available from your Human program that might help you pay the premiums for an
Resources Department. employer-sponsored plan.

Newborns’ and Mothers’ Health Protection Act: If you or your dependents are eligible for premium
Group health plans and health insurance issuers
generally may not, under Federal law, restrict benefits for assistance under Medicaid or CHIP, as well as eligible
any hospital length of stay in connection with childbirth for under your employer plan, your employer must allow you
the mother or newborn child to less than 48 hours to enroll in your employer plan if you aren’t already
enrolled. This is called a “special enrollment” opportunity,
following a vaginal delivery, or less than 96 hours and you must request coverage within 60 days of being
following a cesarean section. However, Federal law
generally does not prohibit the mother’s or newborn’s determined eligible for premium assistance. If you have
attending provider, after consulting with the mother, from questions about enrolling in your employer plan, contact
discharging the mother or her newborn earlier than 48 the Department of Labor at askebsa.dol.gov or call 1-866
hours (or 96 hours as applicable). In any case, plans and -444-EBSA (3272).
issuers may not, under Federal law, require that a
provider obtain authorization from the plan or the Consolidated Omnibus Budget Reconciliation Act of
insurance issuer for prescribing a length of stay not in 1985 (COBRA): Your benefits will continue until the
excess of 48 hours (or 96 hours). last day of the month in which you terminate employment,
elect not to participate in the plan, or you cease to be a
Full-Time (benefits eligible) associate of Quarles
Women’s’ Health and Cancer Rights Act of 1998: Petroleum, Inc.
Federal law requires, under the Women’s Health and
Cancer Rights Act, and subject to all Welfare Program
provisions, that a group health plan provide coverage for The Federal Consolidated Omnibus Budget
the following services to an individual receiving plan Reconciliation Act (COBRA) provides insured associates
benefits in connection with a mastectomy: and their qualified beneficiaries the opportunity to
? Reconstruction of the breast on which the continue health and dental insurance coverage when a
qualifying event would normally result in the loss of
mastectomy was performed; coverage eligibility. Common qualifying events include
? Surgery and reconstruction of the other breast to resignation or termination from employment, the death of
an associate, a reduction in associate's hours, an
produce symmetrical appearance; and associate's divorce, and dependent child no longer
? Prostheses and treatment for physical complications meeting eligibility requirements.

of all stages of mastectomy, including lymphedema
(swelling associated with the removal of lymph
nodes).
As outlined in your General Notice of COBRA Rights,
COBRA requires that you notify Human Resources at
The group health plan must determine the manner of Quarles Petroleum, Inc. when any of the events listed
coverage in consultation with the attending physician and below occur. You must do so within 60 days of the later
patient. Coverage for breast reconstruction and related of (1) the date of the qualifying event or (2) the date
services will be subject to deductibles and coinsurance coverage would be lost as a result of the qualifying event.
amounts that are consistent with those that apply to other
benefits under the plan. ? Divorce or legal separation of the associate and
spouse;

? A dependent child's losing eligibility for coverage as
a dependent child; or

? A second qualifying event

16 2016-2017 Benefits Guide