2015 Benefits Guide_BRVC

2015

Employee Benefits Guide

December 1, 2014 – November 30, 2015

BISHOP RANCH VETERINARY CENTER | 2000 Bishop Drive, San Ramon, California 94583

2015 EMPLOYEE BENEFITS

About Your Benefits
At Bishop Ranch Veterinary Center, we strive to offer a comprehensive and competitive benefits package to our employees. You
have the opportunity to select the coverage that best fits your needs when you first become eligible for benefits and subsequently
at each Open Enrollment held in November of each year for a December 1 effective date. The goal of this guide is to walk you
through your benefits and help you understand the options available to you.

Table of Contents

BENEFITS ELIGIBILITY .......................................................................................................................................1
MEDICAL BENEFITS – Blue Shield of CA ...........................................................................................................3
MEDICAL BENEFITS – Kaiser Permanente........................................................................................................4
DENTAL BENEFITS ............................................................................................................................................5
VISION DISCOUNT SERVICES ............................................................................................................................6
CONTACT INFORMATION & RESOURCES .........................................................................................................7
MEDICARE PART D NOTICE ..............................................................................................................................8
WOMEN’S HEALTH AND CANCER RIGHTS ACT ..............................................................................................10
HEALTH INSURANCE MARKETPLACE COVERAGE...........................................................................................11
HIPAA NOTICE OF SPECIAL ENROLLMENT .....................................................................................................13
DESIGNATION OF PRIMARY CARE PROVIDER ................................................................................................14
THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)..............................................................................15

BENEFITS ELIGIBILITY

New Hire Waiting Period
Full time employees are benefit eligible on the 1st of the month following 30 days of continuous employment.

Who is Eligible?
To be eligible for Bishop Ranch Veterinary Center’ benefits, you must work at least 30 hours per week. You may choose to enroll
your eligible dependents in either the medical or dental benefits coverage or both. Eligible dependents include:

 Your spouse or qualified domestic partner
 Your eligible dependent children up to age 26, regardless of full time student or marital status
 Employees who experience a status change (such as part-time to full-time employment) may enroll in the plan on the first

day of the month following the date of change as long as you have completed at least 30 days of employment

Domestic Partner Eligibility Criteria
If you are enrolling a domestic partner, you will be asked to attest to your domestic partner relationship and that you have met all
eligibility requirements listed below for the previous twelve months.

 You maintain the same principal place of residence and intend to do so in the future
 You agree to be responsible for each other’s basic living expenses in the event that either of you is unable to provide such

expenses for himself or herself
 You are both 18 or older
 Neither of you is married
 You are not related by blood to such a degree that you would be prevented from marrying in the state in which you reside
 Neither of you has maintained coverage for another Domestic Partner under any Kaiser HMO Plans within the last six (6)

months. (This excludes any domestic partner that has died within the last six months.)
 You agree to notify Bishop Ranch Veterinary Center immediately upon your inability to satisfy any of the criteria of Domestic

Partnership

Making Changes
You can make changes to your benefit choices once a year, during the Bishop Ranch Veterinary Center Open Enrollment period
in November. All changes are effective December 1, and all coverages you select will be effective for a full plan year. Because
many of your benefits are available on a pre-tax basis, the IRS requires you to have a change in family status (a qualifying event)
in order to make changes during the year. The IRS defines family status change as:

 Marriage, legal separation or divorce
 Domestic partnership
 Birth, adoption or custody change of an eligible dependent
 Beginning or ending of a spouse’s or domestic partner’s employment
 An increase in the cost of health care coverage for you and your spouse or domestic partner because of your spouse’s or

domestic partner’s employment
 A change in employment (for either you or your spouse) from part-time to full-time or vice versa

Identification (ID) Cards
After you enroll, you will receive ID cards for the medical and dental plan you select. You will not receive ID card for vision
coverage from VSP. When you receive ID card, confirm that all information is accurate. If not, contact benefit carrier right away.

1

BENEFITS ELIGIBILITY (continued)

If You Waive Coverage
If you choose to waive medical, dental, or vision coverage, you may be subject to pre-existing and/or benefit waiting periods
should you become eligible to enroll in the future. Please refer to each carrier’s detailed evidence of coverage booklet for
additional information.
If You Leave Your Job
Your employer-sponsored benefits will end on the last day of the month for medical, dental, and vision. You and your dependents
who are covered under your medical, dental and vision, have the right to continue participation in group health coverage as
allowed under the Consolidated Omnibus Budget Reconciliation Act (commonly referred to as “COBRA”). You have 60 days from
your notification date or coverage-end date to enroll in COBRA. If you enroll COBRA, you will pay monthly payments for the full
premium plus a 2-percent administration fee. COBRA coverage is generally available for up to 18 months, with additional
extensions available under certain circumstances. For more information, you may contact Arrow Benefits Group directly and
speak to a COBRA representative by calling 707-992-3771.

2

MEDICAL BENEFITS – Blue Shield of CA

Calendar Year Deductible Access + HMO Medical Plans Shield Spectrum
Calendar Year Out-of-Pocket Enhanced 40 Shield Spectrum PPO 2500 Value
Maximum Network Coverage PPO 750 Value Network Coverage
Calendar Year Brand Rx Deductible Network Coverage $2,500 per member
Lifetime Maximum Benefit None $750 per member $5,500 per member
Coinsurance $4,500 / member $4,000 per member $250 per member
Hospital Services $9,000 / family $250 per member
$300 per member Unlimited
Inpatient Hospitalization Unlimited Covered at 65%
Emergency Room Unlimited Covered at 70%
Covered at 60% 35%
(Copay waived if admitted) 30% $100 + 35%
40% $100 + 30%
Physician Services $150 copay per visit $45 copay – 1st 3 visits
$15 copay – 1st 3 visits then 35%
Office Visits $40 copay then 30% 35%
30%
Specialist Visits $45 copay Covered at 100%
Preventive Care Covered at 100% Covered at 100% 35%
Maternity (Pre-/Post-Natal Care) Covered at 100% 30%
Outpatient Services 35%
30% $100 + 35%
Diagnostic X-Ray & Lab Covered at 100% $100 + 30% $500 + 30%
MRI, CT Scan and PET Covered at 100% $250 + 30%
$15
Outpatient Surgery 40% $15 $30
Prescription Drugs RX $30 Not covered
Not covered 30-day supply
Retail Pharmacy 30-day supply
Generic $10 $30
Brand Formulary after ded $30 $30 $60
Brand Non-Formulary after ded $50 $60 Not covered
Not covered 90-day supply
Number of Day Supply 30-day supply 90-day supply
Mail-Order Pharmacy Program 35%
Generic $20 30% $45 copay – 1st 3 visits
Brand Formulary after ded $60 $15 copay – 1st 3 visits
Brand Non-Formulary after ded $100 then 35%
then 30%
Number of Day Supply 90-day supply

Mental or Nervous Disorders & Substance Abuse

Inpatient 40%
Outpatient – Office Visit $40 copay

3

MEDICAL BENEFITS – Kaiser Permanente

Calendar Year Deductible Traditional HMO Medical Plans HSA HMO
Deductible HMO Network Coverage
HMO $30 HMO $30/$1,500
None $1,500 / Member $2,700/ Member
$3,000 / Family $5,450 / Family
Calendar Year Out-of-Pocket $3,000 / member $3,500 / Member $4,500 / Member
Maximum $6,000 / family $7,000 / Family $9,000 / Family
Calendar Year Brand Rx Deductible $250 per member Not applicable
Lifetime Maximum Benefit No deductible
Coinsurance Unlimited Unlimited Unlimited
Hospital Services 100% 100% 100% after ded

Inpatient Hospitalization $400 per day $500 per day after ded $450 per day after ded
Emergency Room $100 copay per visit $100 after ded $100 after ded

(Copay waived if admitted) $30 copay 100% after ded
$30 copay 100% after ded
Physician Services Covered at 100% Covered at 100%
Covered at 100% Covered at 100%
Office Visits $30 copay
Specialist Visits $30 copay $10 copay after ded 100% after ded
Preventive Care Covered at 100% $50 copay after ded $50 copay after ded
Maternity (Pre-/Post-Natal Care) Covered at 100%
$250 after ded $250 after ded
Outpatient Services

Diagnostic X-Ray & Lab $10 copay
MRI, CT Scan and PET $50 copay

Outpatient Surgery $200
Prescription Drugs RX

Retail Pharmacy $10 $10 $10 after ded
Generic $30 $30 after ded
30-day supply 30-day supply
Brand Formulary $35 after ded
Number of Day Supply 100-day supply $20 $20 after ded
Mail-Order Pharmacy Program $60 $60 after ded
Generic $10 100-day supply 100-day supply
Brand Formulary $35 after ded
Number of Day Supply 100-day supply $500 per day after ded $450 per day after ded
$30 copay 100% after ded
Mental or Nervous Disorders & Substance Abuse

Inpatient $400 per day
Outpatient – Office Visit $30 copay

4

DENTAL BENEFITS

Calendar Year Deductible Premier Choice Network Network Non-Network
$25 single $50 single $50 single
Deductible Waived for Preventive $50 family $150 family $150 family
Annual Benefits Maximum Yes Yes
Yes
Coinsurance – Coverage Pays $1,500 per member $1,500 per member
Diagnostic and Preventive $1,500 per member
Basic Contracted Rate 90th UCR
Endodontics and Periodontics Contracted Rate
Major 100% 100%
90% 100% 80%
Orthodontia 90% 80% 80%
60% 80% 50%
Not covered 50% Not covered
Not covered

Dental Claims Address: Premier Access Claim Dept., P.O. Box 659010, Sacramento, CA 95865-9010

Find a Premier Dental Network provider on the web
Go to www.PremierLife.com
1 – Select the Members tab
2 – Then click Find a Dentist

Or

Call Premier Access Customer Service: 800-715-0760

Or

Email [email protected]

5

VISION DISCOUNT SERVICES

Bishop Ranch Veterinary Center provides you with vision care coverage through Vision Service Plan (VSP). With this plan, you
can see any vision provider you wish for vision care, and may purchase your glasses at any location. When you obtain services
from providers who participate in the VSP network, your coverage benefits is greater. When you obtain services from providers
who do not participate in the network, your out-of-pocket expenses will be higher.

Benefits VSP Network Frequency of Covered Services
Exam Covered 100% Every 12 months
Lens Every 12 months
Frame Covered 100% Every 24 months
Copay Covered 100%
Covered 100% $25 exam & materials
Exams: Out-of-Network
Lenses: Covered 100% $50 allowance
$130 allowance
Single $130 allowance $50 allowance
Bifocal $70 allowance
Trifocal $100 allowance
Contacts (in lieu of glasses)
Medically Necessary $210 allowance
Elective $105 allowance
Frames $70 allowance

•••••••••••••••••••••••••••••••••••••••••••••

How to Use VSP

Locate a VSP doctor near you. You may either use our Web-based doctor locator at ww.vsp.com or call VSP at 800-877-7195 to
request a doctor listing.

Identify yourself as being eligible for the VSP discount and be prepared to provide your Social Security Number when you make
your appointment. (The VSP doctor will verify your eligibility and applicable discount. If you are not currently eligible for the
discount, the VSP doctor is responsible for communicating this to you.)

Your fees are automatically reduced at the time of service – with no claim forms to fill out!

6

CONTACT INFORMATION & RESOURCES

Carriers Group No. Member Services Website
Blue Shield of California 4415779 888-256-3650 www.blueshieldca.com
Kaiser Permanente HMO 655739 800-464-4000 www.kp.org
Premier Access Dental 15416 888-715-0760 www.premierlife.com
VSP Vision 12228149 800-877-7195 www.vsp.com

7

MEDICARE PART D NOTICE
CREDITABLE COVERAGE

Important Notice from Bishop Ranch Veterinary Center 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 BISHOP RANCH VETERINARY CENTER 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. BISHOP RANCH VETERINARY CENTER has determined that the prescription drug coverage offered by the
KAISER PERMANENTE and BLUE SHIELD OF CA 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 -
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 coverage may be affected

If you do decide to join a Medicare drug plan and drop your current BISHOP RANCH VETERINARY CENTER
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 BISHOP RANCH VETERINARY CENTER
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.

8

MEDICARE PART D NOTICE - continued

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

Contact Donna Lemmon at 415-455-8481 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 BISHOP
RANCH VETERINARY CENTER 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: December 1, 2014
Name of Entity/Sender: BISHOP RANCH VETERINARY CENTER
Contact--Position/Office: Margaret Urquhart, Hospital Administrator
Address: 2000 Bishop Drive, San Ramon, California 94583
Phone Number: 925-327-0790

9

WOMEN’S HEALTH AND CANCER RIGHTS ACT

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 lymphedemas?
The Women’s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits
available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy
patients for:

 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
 Treatment of physical complications of the mastectomy, including lymphedema

Contact Kaiser Permanente at 800-464-4000 or Blue Shield of CA at 888-256-3650 for more information.

10

HEALTH INSURANCE MARKETPLACE COVERAGE

PART A: General Information

When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the
Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides
some basic information about the new Marketplace and employment based health coverage offered by your
employer.

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. You may also be
eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health
insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1,
2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer
coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're
eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be
eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However,
you may be eligible for a tax 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 meets certain standards. If
the cost of a plan from your employer that would cover you (and not any other members of your family) is more
than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the
"minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by
your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this
employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded
from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace
are made on an after-tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan
description or contact your Human Resources department.

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.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed
benefit costs covered by the plan is no less than 60 percent of such costs.

11

HEALTH INSURANCE MARKETPLACE - continued

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.

3. Employer name 4. Employer Identification Number (EIN)

Bishop Ranch Veterinary Center 68-0453594

5. Employer address 6. Employer phone number

2000 Bishop Drive

7. City 8. State 9. ZIP code

San Ramon CA 94583

10. Who can we contact about employee health coverage at this job?

Margaret Urquhart, Hospital Administrator

11. Phone number (if different from above) 12. Email address

925-327-0790 [email protected]

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees.

Some employees. Eligible employees are those working at least 30 hours per week

• With respect to dependents:

We do offer coverage. Eligible dependents are: spouse or domestic partner and children

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is
intended to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium
discount through the Marketplace. The Marketplace will use your household income, along with other
factors, to determine whether you may be eligible for a premium discount. If, for example, your
wages vary from week to week (perhaps you are an hourly employee or you work on a commission
basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify
for a premium discount.

12

HIPAA NOTICE OF SPECIAL ENROLLMENT

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 your 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.
Also, you may be entitled to special enrollment rights pursuant to the Children’s Health Insurance Program
Reauthorization Act of 2009 (the Act) if you or your dependents:

1. Lose coverage under a Medicaid or State Plan (such as California’s Medi-Cal); or
2. Become eligible for group health premium assistance under a Medicaid plan or State Plan.
If a special enrollment right is provided pursuant to the Act, you may change your election consistent with such
special enrollment right within 60 days as long as the election is made consistent with the special enrollment.
Waiver of Coverage
If you elect to waive coverage for yourself or your dependents (including your spouse), you acknowledge that
you and your spouse and/or dependent child(ren) can only enroll later during an annual open enrollment period.
An exception to this is if you and your spouse and/or dependent child(ren) are entitled to enroll in accordance
with the “Special Enrollment Rights” described above.

To request special enrollment or obtain more information, contact your Human Resources Department for
assistance.

13

DESIGNATION OF PRIMARY CARE PROVIDER

Blue Shield of California and Kaiser Permanente generally require 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. For information on how to select a primary care provider, and for a list of

the participating primary care providers, contact Blue Shield of CA at 888-256-3650 or Kaiser Permanente at 800-
464-4000 or for more information.

For children, you may designate a pediatrician as the primary care provider.
You do not need prior authorization from Blue Shield of California, Kaiser Permanente, 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. For a list of participating

health care professionals who specialize in obstetrics or gynecology, contact the Blue Shield of CA at 888-256-
3650 or Kaiser Permanente at 800-464-4000 or for more information.

14

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 are eligible for health coverage from your
employer, your State may have a premium assistance program that can help pay for coverage. These States use
funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have
access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP,
you will not be eligible for these premium assistance programs.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can
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, you can contact your State Medicaid or CHIP office or
dial 1-877-KIDS NOW or http://www.insurekidsnow.gov to find out how to apply. If you qualify, you can
ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP,
as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if
you are not 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, you can contact the Department of Labor electronically at http://www.askebsa.dol.gov or by
calling toll-free 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, 2013. You should contact
your State for further information on eligibility –

ALABAMA – Medicaid COLORADO – Medicaid

Website: http://www.medicaid.alabama.gov Medicaid Website: http://www.colorado.gov/
Phone: 1-855-692-5447 Medicaid Phone (In state): 1-800-866-3513
Medicaid Phone (Out of state): 1-800-221-3943
ALASKA – Medicaid

Website:
http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890

Phone (Anchorage): 907-269-6529

ARIZONA – CHIP FLORIDA – Medicaid

Website: http://www.azahcccs.gov/applicants Website: https://www.flmedicaidtplrecovery.com/
Phone (Outside of Maricopa County): 1-877-764-5437 Phone: 1-877-357-3268
Phone (Maricopa County): 602-417-5437
GEORGIA – Medicaid

Website: http://dch.georgia.gov/

Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)

Phone: 1-800-869-1150

15

IDAHO – Medicaid and CHIP MONTANA – Medicaid

Medicaid Website: Website:
www.accesstohealthinsurance.idaho.gov http://medicaidprovider.hhs.mt.gov/clientpages/
Medicaid Phone: 1-800-926-2588
CHIP Website: www.medicaid.idaho.gov clientindex.shtml
CHIP Phone: 1-800-926-2588
Phone: 1-800-694-3084

INDIANA – Medicaid NEBRASKA – Medicaid

Website: http://www.in.gov/fssa Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949 Phone: 1-800-383-4278

IOWA – Medicaid NEVADA – Medicaid

Website: www.dhs.state.ia.us/hipp/ Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562 Medicaid Phone: 1-800-992-0900

KANSAS – Medicaid

Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid

Website: http://chfs.ky.gov/dms/default.htm Website:
Phone: 1-800-635-2570 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP

Website: http://www.lahipp.dhh.louisiana.gov Medicaid Website:
Phone: 1-888-695-2447 http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
MAINE – Medicaid
Medicaid Phone: 609-631-2392
Website: http://www.maine.gov/dhhs/ofi/public-
assistance/index.html CHIP Website: http://www.njfamilycare.org/index.html
Phone: 1-800-977-6740
TTY 1-800-977-6741 CHIP Phone: 1-800-701-0710

MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid

Website: http://www.mass.gov/MassHealth Website:
Phone: 1-800-462-1120 http://www.nyhealth.gov/health_care/medicaid/

Phone: 1-800-541-2831

MINNESOTA – Medicaid NORTH CAROLINA – Medicaid

Website: http://www.dhs.state.mn.us/ Website: http://www.ncdhhs.gov/dma
Click on Health Care, then Medical Assistance Phone: 919-855-4100
Phone: 1-800-657-3629

MISSOURI – Medicaid NORTH DAKOTA – Medicaid

Website: Website:

http://www.dss.mo.gov/mhd/participants/pages/hipp.h http://www.nd.gov/dhs/services/medicalserv/medicaid/

tm Phone: 1-800-755-2604

Phone: 573-751-2005

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OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742 Website: http://health.utah.gov/upp
Phone: 1-866-435-7414
OREGON – Medicaid and CHIP
Website: http://www.oregonhealthykids.gov VERMONT– Medicaid
http://www.hijossaludablesoregon.gov Website: http://www.greenmountaincare.org/
Phone: 1-800-699-9075 Phone: 1-800-250-8427

PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP
Website: http://www.dpw.state.pa.us/hipp Medicaid Website: http://www.dmas.virginia.gov/rcp-
Phone: 1-800-692-7462 HIPP.htm
Medicaid Phone: 1-800-432-5924
RHODE ISLAND – Medicaid CHIP Website: http://www.famis.org/
Website: www.ohhs.ri.gov CHIP Phone: 1-866-873-2647
Phone: 401-462-5300
WASHINGTON – Medicaid
SOUTH CAROLINA – Medicaid Website:
Website: http://www.scdhhs.gov http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 1-888-549-0820 Phone: 1-800-562-3022 ext. 15473

SOUTH DAKOTA - Medicaid WEST VIRGINIA – Medicaid
Website: http://dss.sd.gov Website: www.dhhr.wv.gov/bms/
Phone: 1-888-828-0059 Phone: 1-877-598-5820, HMS Third Party Liability

TEXAS – Medicaid WISCONSIN – Medicaid
Website: https://www.gethipptexas.com/ Website: http://www.badgercareplus.org/pubs/p-
Phone: 1-800-440-0493 10095.htm
Phone: 1-800-362-3002

WYOMING – Medicaid
Website:
http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531

To see if any more States have added a premium assistance program since July 31, 2013, or for more
information on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa http://www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

OMB Control Number 1210-0137 (expires 09/30/2013)

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