Important Notices and Disclosures
HIPAA Special Enrollment Rights
DAVIS BEHAVIORAL HEALTH PLAN NOTICE OF YOUR HIPAA SPECIAL ENROLLMENT RIGHTS
Our records show that you are eligible to participate in the Davis Behavioral Health Plan ( to actually participate , you must complete an enrollment form and pay part of the premium through payroll deduction ).
A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “ special enrollment provision ” if you acquire a new dependent , or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons .
Loss of Other Coverage ( Excluding Medicaid or a State Children ’ s Health Insurance Program ). If you decline enrollment for yourself or for an eligible dependent ( including your spouse ) while other health insurance or group health plan coverage is in effect , you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage ( or if the employer stops contributing toward your or your dependents ’ other coverage ). However , you must request enrollment within 30 days after your or your dependents ’ other coverage ends ( or after the employer stops contributing toward the other coverage ).
Loss of Coverage for Medicaid or a State Children ’ s Health Insurance Program . If you decline enrollment for yourself or for an eligible dependent ( including your spouse ) while Medicaid coverage or coverage under a state children ’ s health insurance program is in effect , you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage . However , you must request enrollment within 60 days after your or your dependents ’ coverage ends under Medicaid or a state children ’ s health insurance program .
New Dependent by Marriage , Birth , Adoption , or Placement for Adoption . 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 new dependents . However , you must request enrollment within 30 days after the marriage , birth , adoption , or placement for adoption .
Eligibility for Premium Assistance Under Medicaid or a State Children ’ s Health Insurance Program – If you or your dependents ( including your spouse ) become eligible for a state premium assistance subsidy from Medicaid or through a state children ’ s health insurance program with respect to coverage under this plan , you may be able to enroll yourself and your dependents in this plan . However , you must request enrollment within 60 days after your or your dependents ’ determination of eligibility for such assistance .
To request special enrollment or to obtain more information about the plan ’ s special enrollment provisions , contact Kathi Hanson - Human Resources at 801.336.1845 or kathih @ dbhutah . org .
IMPORTANT WARNING
If you decline enrollment for yourself or for an eligible dependent , you must complete our form to decline coverage . On the form , you are required to state that coverage under another group health plan or other health insurance coverage ( including Medicaid or a state children ’ s health insurance program ) is the reason for declining enrollment , and you are asked to identify that coverage . If you do not complete the form , you and your dependents will not be entitled to special enrollment rights upon a loss of other coverage as described above , but you will still have special enrollment rights when you have a new dependent by marriage , birth , adoption , or placement for adoption , or by virtue of gaining eligibility for a state premium assistance subsidy from Medicaid or through a state children ’ s health insurance program with respect to coverage under this plan , as described above . If you do not gain special enrollment rights upon a loss of other coverage , you cannot enroll yourself or your dependents in the plan at any time other than the plan ’ s annual open enrollment period , unless special enrollment rights apply because of a new dependent by marriage , birth , adoption , or placement for adoption , or by virtue of gaining eligibility for a state premium assistance subsidy from Medicaid or through a state children ’ s health insurance program with respect to coverage under this plan .
Davis Behavioral Health
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