A Guide to Your Employee Benefits - CDU at 50
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A Guide to Your Employee Benefits
2021
Welcome! Your well-being is important to us.
Charles R. Drew University of Medicine and Science (“CDU”) continues
to offer health and wellness benefits to help you stay healthy and provide
financial protection against high medical costs. The program incorporates
a variety of benefit plans from which employees can choose and the
following pages provide a brief overview of the benefits available. The
various plans made available are very comprehensive.
TABLE OF CONTENTS
Eligibility & Enrollment 2
Employee Contributions 3
Health Care Reform
Medical 4
You have heard about
Medical Plans Comparison 5
Healthcare Reform and the public
health insurance marketplaces, Medical Carrier Programs 6-7
including Covered California. Dental 8
Individuals who are not offered
Vision 9
qualified healthcare coverage
Basic and Voluntary Life and Accidental Death &
through their employer may be 10-11
Dismemberment
eligible for tax subsidies to help
Short Term Disability 12
pay for health insurance
premiums for plans purchased in Long Term Disability 13
the public marketplaces (based Unum Voluntary Insurance 14
on the level of income and
Flexible Spending Accounts 15
number of dependents). Due to
the high standard of health Employee Assistance Program 16
coverage CDU offers, our
Other Benefits 17-18
employees will generally NOT be
University Holidays 19
eligible for these subsidies.
Carrier/Vendor Contact Information 20
Required Notices 21-28
If you have Medicare or will become eligible for Medicare
in the next 12 months, a federal law gives you more
choices about your prescription drug coverage. Please
see page 27-28 for details.
PAGE 1
ELIGIBILITY & ENROLLMENT
ELIGIBLE EMPLOYEES
You may enroll in our benefits program if you are a Regular or Conditional
employee working a minimum of 20 paid hours per week.
ELIGIBLE DEPENDENTS
As you become eligible for benefits, so do your eligible dependents. In general,
CHANGES IN BENEFIT eligible dependents include your spouse or registered/unregistered domestic
ELECTIONS partner (same or opposite sex), and children up to the age of 26 for Medical,
Each year, during Open
Dental, Vision, and Voluntary Life. If your child is mentally or physically
Enrollment, you will have the disabled, coverage may continue beyond the age of 26. Children may include
opportunity to change your natural, adopted, stepchildren, or domestic partner’s children.
elections for the following plan
year.
WHEN COVERAGE BEGINS
In general, only during Open Employees will be eligible for Medical, Dental, Vision, Life, Disability, EAP and
Enrollment will you have the FSA benefits on the first day of the month following date of hire with CDU and
opportunity to: completion of the required paperwork. All elections are in effect for the entire
plan year and can only be changed during Open Enrollment or if you
Add or terminate coverage experience a qualified status change.
Add or terminate dependents
from coverage NOTE: If you do not make health benefit elections within 30 days of your
eligibility date, you will be deemed to have waived coverage until the next open
enrollment period.
FSA ELECTIONS
Each year. you will also need to WHEN COVERAGE ENDS
re-enroll for your FSA elections. In general, your coverage under CDU’s Medical, Dental, and Vision plans ends
the last day of the month in which you terminate employment. Your coverage
under CDU’s Life, Disability, EAP, and FSA plans ends on your last day of
QUESTIONS ABOUT YOUR
BENEFITS? active employment. Covered employees and qualified dependents are
permitted to continue certain coverages at their own expense after leaving
The CDU Benefits Call Center CDU as provided by federal law (COBRA).
and Benefits portal are available
to assist you with any benefit QUALIFIED STATUS CHANGES
questions you may have.
You can make some limited changes during the year due to a Qualified Status
The Benefits Call Center is Change. You must notify CDU within 30 days of a qualified status change.
available: Some qualified status changes may include:
Monday – Thursday: • Marriage or divorce
5am - 5pm PST, and
Friday: 5am – 3pm PST • Birth of a child
• Spouse’s termination or commencement of employment
(855) 230-0745,
extension 6412 • A reduction or increase in hours of employment by the participant, spouse,
customersupport@benxcel.com or dependent, including a shift between part-time and full-time status, or
going on or returning from an extended leave of absence
www.benxcel.net
PAGE 2
EMPLOYEE CONTRIBUTIONS
Your benefit contributions are automatically payroll deducted each pay period. Contributions for Medical, Dental,
Vision, and Flexible Spending Accounts are deducted on a pre-tax basis. Deductions for certain other benefits
are deducted on an after-tax basis in order to receive a tax-free benefit at time of claim.
The IRS requires that you pay taxes for domestic partner coverage if your domestic partner and the children of
your domestic partner are not considered your IRS tax dependent. This impacts you in two ways. First, your
payroll contribution for domestic partner coverage is an after-tax deduction. Second, CDU’s cost of providing
domestic partner coverage is added to your taxable income. Please contact Human Resources for a detailed
description of the domestic partner requirements.
CARRIER COVERAGE CATEGORY EMPLOYEE CDU
SEMI-MONTHLY SEMI-MONTHLY
COST COST
EE Only $52.50 $244.71
Kaiser Medical HMO EE + Spouse $168.48 $485.39
EE + Child(ren) $128.05 $406.93
EE + Family $222.39 $698.97
EE Only $52.50 $290.09
Aetna Medical HMO EE + Spouse $168.48 $585.22
EE + Child(ren) $128.05 $488.60
EE + Family $222.39 $839.70
EE Only $100.60 $439.91
Aetna Medical OAMC EE + Spouse $290.80 $898.30
EE + Child(ren) $229.26 $743.64
EE + Family $398.17 $1277.48
EE Only $1.75 $5.69
DeltaCare Dental HMO EE + Spouse $4.42 $8.40
USA EE + Child(ren) $4.21 $9.34
EE + Family $6.53 $14.34
EE Only $5.54 $20.58
Delta Dental Dental PPO EE + Spouse $14.63 $37.29
of CA EE + Child(ren) $16.68 $38.20
EE + Family $25.37 $59.17
EE Only $2.57 $1.19
VSP Vision EE + Spouse $4.11 $3.41
EE + Child(ren) $3.30 $3.84
EE + Family $5.19 $6.08
Basic Life / AD&D EE Only Employer Paid
Cigna Dependent Life Dependents Employee Paid
Voluntary Life EE + Family Employee Paid
Voluntary AD&D EE + Family Employee Paid
MHN EAP EE + Family Employer Paid
Cigna STD / LTD EE Only Employer Paid
BCC Health Care FSA & Health Care up to Employee Paid
Dependent Care $2,700/yr.
FSA Dep. Care up to
$5,000/yr.
Unum Supplement EE + Family Employee Paid
Products
PAGE 3
MEDICAL
CDU has three medical plans to choose from. Please refer to our Medical
Plan Comparison Chart on the next page for more details about these
plans, or refer to your carrier benefit summaries.
AETNA HMO
The Aetna HMO plan is designed for you to visit providers that are only
contracted with Aetna. You will need to choose a Primary Care Physician
(PCP) and coordinate care with any Specialists through this PCP. Note
that services received outside the Aetna HMO network are not covered
LOCATE A PROVIDER except for emergency services.
To find participating providers, AETNA OPEN ACCESS MANAGED CHOICE (OAMC)
go to
The Aetna OAMC plan offers more flexibility in selecting providers. As a
http://www.aetna.com/docfind/
OAMC plan member, you may receive health care services from any
home.do
licensed health care provider. However, if you choose an in-network
or www.kp.org for a local
provider (a provider who belongs to the Aetna Open Access network),
Kaiser Permanente facility.
claims will be submitted to Aetna for you and there is a significant cost
savings compared to using a non-network OAMC provider. When using
non-OAMC health care providers, members are responsible for any
difference between the in-network contracted rate and the actual charges,
as well as any deductible and coinsurance percentage.
KAISER PERMANENTE HMO
Under the Kaiser HMO plan, most services are covered in full or require a
co-pay through Kaiser. You may select a Primary Care Physician from any
of the Kaiser Permanente locations, but it is not required.
You can enroll in the Kaiser Permanente HMO if you live or work within the
Kaiser service area. Under the plan, you must receive non-emergency,
routine and scheduled services (e.g., preventive care appointments, school
physicals) from Kaiser physicians and facilities. Emergency care is covered
at any hospital facility, including non-Kaiser facilities.
PRESCRIPTION DRUGS
If you are on a maintenance medication (e.g. high blood pressure, allergies,
birth control, or other daily medications), you can save time and money by
having your prescriptions dispensed through the mail order program.
Please note that the prescription drug formulary lists are periodically
updated by the insurance carriers. Based on these updates, some
drugs will change Rx tier, may require step therapy/pre-authorization
or may require an alternative drug. These updates generally apply to
all of the carrier’s plans, not just to CDU’s plan.
PAGE 4
MEDICAL PLANS COMPARISON
Each medical plan charges different co-pays and coinsurance for various services. The chart below provides a
comparison of basic costs and services of the plans CDU offers. This chart is only a partial listing of plan features.
MEDICAL PLAN OPTIONS
KAISER AETNA OPEN ACCESS MANAGED CHOICE (OAMC)
FEATURE OR SERVICE AETNA HMO
PERMANENTE HMO NETWORK NON-NETWORK
Annual Deductible None None $1,000 / M ember $2,000 / M ember
$2,000 / Family $4,000 / Family
Out-of-Pocket Maximum
Individual $1,500 $2,000 $3,500 $7,000
Family $3,000 $4,000 $7,000 $14,000
Office Visit $30 per visit $15 per visit (PCP) $25 per visit (PCP) 40% after deductible
$30 per visit (Specialist) $50 per visit (Specialist)
Preventive (physical No charge No charge No charge 40% after deductible
exams, well-baby, etc) (deductible waived)
Most X-Ray & Lab No charge No charge 20% after deductible 40% after deductible.
Urgent Care $30 copay $35 copay $35 copay 40% after deductible
Emergency Room $100 copay $150 copay $150 copay + 20% $150 copay + 20%
(copay waived if admitted)
Chiropractic Not covered $15 per visit $50 (limited to 20 40% after deductible
(20 visits/year) visits/year) (limited to 20 visits/year)
Acupuncture $30 per visit for $15 per visit $50 (limited to 20 40% after deductible
certain services (20 visits/year) visits/year) (limited to 20 visits/year)
Hospital Coverage
Inpatient (to avoid add’l $500 per admit $250 per admit 20% after deductible 40% after deductible
copays, preauthorization
is recommended)
Outpatient $100 per procedure $100 per surgery 20% after deductible 40% after deductible
Prescription Drug
Retail Day Supply: Up to 30 days Up to 30 days Up to 30 days
Preferred Generic $15 copay $10 copay $10 copay Not Covered
Preferred Brand $30 copay $30 copay $30 copay
Non-Preferred Not applicable $50 copay $50 copay
Specialty 30% up to $150/script 20% up to $200/script 20% up to $200/script
Prescription Drug
Mail Order Day Supply: Up to 100 days Up to 90 days Up to 90 days Not Applicable
Preferred Generic $30 copay $20 copay $20 copay
Preferred Brand $60 copay $60 copay $60 copay
Non-Preferred Not applicable $100 copay $100 copay
PAGE 5
AETNA PROGRAMS AND SERVICES
24/7 NURSE LINE – INFORMED HEALTH ® | (800) 556-1555
The Informed Health ® program provides members with telephone and e-mail
access to registered nurses to help them make informed healthcare decisions.
Nurses are available 24 hours a day and 7 days a week.
TELEDOC ® | (855) 835-2362
Teladoc® is a convenient and affordable option for a variety of medical
services, including General Medical, Dermatology and Behavioral Health.
Access quality healthcare from the comfort of home, during your lunch break or
while traveling. You can even get a prescription sent to your local pharmacy,
when medically necessary.
AETNA PROGRAMS HEALTH CONNECTIONS ® DISEASE MANAGEMENT | (866) 269-4500
Health Connections ® is a disease management program that helps members
Informed Health with chronic conditions achieve a healthy outcome through advanced tools,
techniques, and systems. Aetna personalizes the condition coaching for
Teledoc members to motivate and empower them to change their behaviors and
therefore reduce health risks.
Health Connections
BEGINNING RIGHT ® MATERNITY MANAGEMENT | (800) 272-3531
Beginning Bright
Pregnancy can be an exciting time filled with hopes and dreams for your baby!
The most important thing you can do right now to make those dreams come
Simple Steps To a
true is to take good care of yourself. This program is designed to help you
Healthier Life
have a safe delivery and a healthy child. The line is staffed by registered
nurses 24 hours a day, seven days a week.
Discount Programs
• A toll-free number you can call about pregnancy, labor, what to expect before and after
Fitness Discounts delivery , newborn care, and more.
• Some women have health conditions that could affect their pregnancies,. If you do, you can
Rx Mail Order work with a nurse case manager to help you lower those risks.
• Support to quit smoking and help to avoid you going into early labor.
WELLNESS AND DISCOUNT PROGRAMS
Simple Steps To a Healthier Life ® is a road to better health with programs and
resources tailored to meet your needs.
To locate the discounts that are available to you, once you’re an Aetna
member, just log in to your member website at aetna.com. You can find a
vision, hearing or natural therapy professional, sign up for a weight-loss
program, buy health products, find a gym, and more.
PAGE 6
KAISER PERMANENTE
HEALTHY LIVING PROGRAMS
As a Kaiser Permanente member, you have access to discounts on health
products and services through ChooseHealthy. As a comprehensive health
website offering a directory of complementary health care providers,
information about complementary health care services, and discounts on
health and wellness products such as:
• Acupuncture • Chiropractic care
• Massage therapy services • Herbs, vitamins, and supplements
• Fitness club memberships • Health and fitness books and videos
Kaiser | www.kp.org Visit www.kp.org/choosehealthy and click on “complementary care” or call
American Specialty Health at (877) 335-2746 to learn more about this
program, sign up, or take an online tour.
• Manage Your Health
• Schedule Appointments MY HEALTH MANAGER | www.kp.org/register
• Refill Prescriptions My Health manager gives you access to powerful online tools designed to help
you manage your health. You can email your doctor’s office, order prescription
• Email Your Doctor
refills, view most lab test results, request routine appointments, check past
• View Test Results office visit information, look up future appointments, and more. Once you
register, you will be able to get connected in a single visit, without having to
• Tools and Calculators
wait for your password to be emailed to you.
• Health Classes
• Healthy Lifestyle Programs HEALTHY LIFESTYLE PROGRAMS
Kaiser Permanente has collaborated with HealthMedia to offer you programs
such as:
Using the Kaiser Permanente • Manage ongoing health conditions – When you join HealthMedia Care, you
web site, you can access the will receive a plan for managing your symptoms, medication, and
latest healthy lifestyle and treatment, as well as encouraging reminders for making healthy lifestyle
medical information right from changes.
your own home – anytime,
day, or night. Whether you’d • Lose Weight – HealthMedia Balance gives you personalized strategies for
like to quit smoking, lose reaching your ideal weight with a program that’s helped thousands of
weight, control your people lose weight and keep it off.
cholesterol, start a fitness • Eat Right – HealthMedia Nourish gives you personalized strategies for
program, manage your making smart and delicious food choices to increase your energy level,
diabetes, or reduce stress, the manage your weight, and live a healthier life.
Kaiser Permanente website
can help. • Quit Smoking – This award-winning program can help you create a
personalized quitting plan with proven strategies for decreasing your
dependency and dealing with cravings.
• Overcome Stress – Examine your individual sources and symptoms of
stress and develop a customized stress management plan that will help
you start living a healthier and more relaxed life.
PAGE 7
DENTAL
You and your eligible dependents have the option to enroll in one of two
dental plans: the Deltacare Dental DHMO plan or the Delta Dental DPPO
plan.
Under the DeltaCare Dental DHMO, there are no deductibles and most
dental benefits are unlimited. Each family member must select a Primary
Dentist/Facility from the list of Delta Dental dentists when they enroll. All
services and referrals to specialty care will be coordinated by the Primary
Dentist/Facility.
The Delta Dental DPPO allows you the flexibility of seeing a network dentist
and receiving benefits at a discounted rate, or seeing a non-network dentist
and paying the difference between the fee schedule* charges and what your
dentist bills. There is no need to select a dentist at enrollment under the
Dental DPPO plan.
DENTAL PLAN OPTIONS
Using Your Dental FEATURE OR DELTACARE DELTA DENTAL DPPO
Benefits Wisely SERVICE DHMO
NETWORK NON-NETWORK
• To pay the least Deductible None $50 / Individual
amount out-of-pocket,
$150 / Family
always use in-network
dentists under the Deductible Waived N/A Yes
DPPO. on Preventive
Services?
• Use your preventive
Annual Calendar Unlimited $1,500 $1,250
benefits and get
Year Benefit
cleanings for you and
Maximum
your family.
Preventive Services copay schedule No charge 80% covered
• If your services are
estimated to be $350 or Basic Services copay schedule 80% covered
more by your dentist,
be sure to have your
Major Services copay schedule 50% covered
dentist get pre-
determination of
benefits to Delta Dental Orthodontia copay schedule lifetime max of $1,500
to ensure services are
covered and to get an
estimate of what the *Fee Schedule: Claims incurred outside of the Delta Dental PPO dental network
are subject to fee schedule levels. Fee schedule represents the maximum dollar
plan will pay.
amount Delta Dental will pay on certain services. The member is responsible for
any amounts charged over the fee schedule.
PAGE 8
VISION
You have the opportunity to participate in the VSP Vision Plan. The vision
program allows you to utilize VSP’s network of eye care providers or see an
eye care professional outside the network.
NETWORK vs. NON-NETWORK COVERAGE
Dollar for dollar, you get the best value from your vision benefit when you visit a
VSP in-network doctor. If you decide to see a non-network doctor, copays still
apply and you’ll typically receive a lesser benefit. When you use a non-network
doctor, you are required to pay the provider in full at the time of your
appointment and submit a claim form to VSP for reimbursement.
VISION PLAN HIGHLIGHTS
How Long Has It Been FEATURE OR SERVICE NETWORK NON-NETWORK
Since Your Last Eye
Deductible for Materials $20
Exam?
Exams $15 $45 Allowance
Your eyes provide a clear
view of your blood Lenses*
vessels. Optometrists and Single Paid in full $30 Allowance
Ophthalmologists can be Lined-Bifocal Paid in full $50 Allowance
the first to detect Lined-Trifocal Paid in full $65 Allowance
symptoms of illnesses Frames $120 Retail Allowance $70 Allowance
such as cardiovascular (plus 20% off amount
disease, diabetes, and over the allowance)
thyroid disorders.
Contacts** $120 Retail Allowance $105 Retail Allowance
(including fitting &
evaluation)
Frequency
Exams 12 Months
Lenses 12 Months
Frames 12 Months
Contacts (in lieu of lenses 12 Months
& frames)
*Members may be offered discounted fees for extra features added to lenses such as
tinting, scratch coating, and progressive (blended bifocals) lenses when they utilize VSP
providers.
**Members have the choice between lenses or contacts each 12-month interval. If you
choose contact lenses, you will not be eligible for a frame for 12 months following the
date contacts were obtained. Note, the contact lens evaluation fee and fitting costs are
separate from the comprehensive vision care exam.
LASER VISION CARE
VSP has contracted with many of the nation’s laser surgery facilities and
doctors, offering members discounts off laser vision correction surgeries,
available through contracted laser centers. Contact VSP to learn more.
PAGE 9BASIC AND VOLUNTARY LIFE AND
ACCIDENTAL DEATH & DISMEMBERMENT
Life insurance is an important part of a complete benefits package offered by
CDU. CDU pays 100% of the cost of a Basic Life and Accidental Death &
Dismemberment (AD&D) for all eligible employees through Cigna.
BASIC LIFE & AD&D INSURANCE
The basic life policy will pay a benefit of one times your annual salary to a
maximum of $400,000, with a minimum benefit of $50,000. The benefit amount
will reduce to 65% of the original amount when you reach age 65, and to 50%
of the original amount at age 70.
NOTE: To avoid imputed income on the premium for life insurance amounts
over $50,000, you may opt to reduce your Basic Life/AD&D coverage to
$50,000.
VOLUNTARY LIFE COVERAGE
CDU also offers voluntary life insurance. You may purchase additional Life
insurance, for not only yourself, but also your dependents. The coverage
Voluntary Life Insurance amount will reduce to 65% at age 65 and 45% at age 70. You are eligible to
Features purchase the following amounts:
Accelerated Benefit: VOLUNTARY LIFE PLAN OPTIONS
If you become terminally ill
and are not expected to COVERAGE TYPE COVERAGE AMOUNTS
live beyond a certain
Employee • In increments of $10,000
period, you may request a
• The lesser of $500,000 or 5x salary
% of your life insurance
• Guarantee Issue $100,000 (new employees only)
amount (to a certain
maximum). Upon your Spouse/Domestic Partner • In increments of $5,000
death, the remaining • Maximum 50% of Employee Face Amount, not to
benefit will be paid to the exceed $250,000
designated • Guarantee Issue $50,000 (new employees only)
beneficiary(ies).
Children • In increments of $2,000
Portability & Conversion: • Maximum of $10,000
If you retire, reduce your • Birth to 6 months limited to $1,000 coverage amount
hours, or terminate
employment, you can OPTIONAL DEPENDENT LIFE COVERAGE
generally take this You also have the option to purchase life insurance in the amount of $5,000 for
coverage with you your spouse and $2,000 for your dependent child(ren).
according to the terms
outlined in the contract. VOLUNTARY LIFE MEDICAL UNDERWRITING
The Guarantee Issue amounts apply only when you are first eligible for
benefits under the CDU plan. If you (and/or your dependents) do not elect
voluntary life insurance coverage when first eligible, the entire amount of life
insurance elected will require medical underwriting.
Please note that certain changes during the year (e.g., salary updates) could
result in an adjustment to your payroll deduction amounts .
PAGE 10VOLUNTARY ACCIDENTAL DEATH AND
DISMEMBERMENT (AD&D) INSURANCE COVERAGE
You: All active, Full-Time Employees of the Employer regularly working a
minimum of 20 hours per week in the United States, who are citizens or
permanent resident aliens of the United States.
Your Spouse*: Up to age 70, as long as you apply for and are approved for
coverage yourself.
Your Child(ren): Is eligible as long as you apply for and are approved for
coverage yourself.
*Domestic Partner is defined in the Group Policy. For purposes of this
brochure, wherever the term Spouse appears, it shall also include Domestic
Partner registered under any state which legally recognizes Domestic
Partnerships or Civil Unions. Additional information is available from your
Benefit Services Representative.
VOLUNTARY AD&D PLAN
BENEFIT AMOUNTS MAXIMUM
Employee Units of $10,000 Lesser of 5 times salary or
$500,000
Spouse Units of $5,000 $250,000
Children Units of $2,000 $10,000
OPTIONAL DEPENDENT AD&D COVERAGE
You also have the option to purchase life insurance in the amount of $5,000 for
your spouse and $2,000 for your dependent child(ren).
PAGE 11SHORT TERM DISABILITY
CDU has purchased Short Term Disability (STD) on your behalf. Our short
term disability program provides a source of weekly income should you
become disabled and you are unable to work.
Benefits are paid for any non-occupational illness or injury that causes
disability, including pregnancy and pre-existing conditions. The amount of
your benefit equals 60% of your pay, up to a weekly maximum benefit of
$1,750.
SHORT TERM DISABILITY BENEFITS
FEATURE BENEFIT
Income Replacement 60%
Weekly Maximum $1,750
Benefit Waiting Period 60 days for accident
60 days for sickness
Maximum Benefit Period 26 weeks (includes Benefit Waiting Period)
Why are Short Term Disability
benefits important?
• 2/3 of disabilities are non-
work related and therefore,
are not covered by worker’s
compensation.
• Managing treatment early,
especially for disabilities that
could become long-term, can
mean better outcomes.
PLEASE NOTE!
Benefits are integrated with any
amount you receive, or are
entitled to receive, under such
things as any state compulsory
benefit act or law, or Social
Security disability.
PAGE 12LONG TERM DISABILITY
Long-Term Disability insurance is an essential part of a complete benefits
package offered by CDU. This program covers disabling injuries or
sicknesses that laCDU pays 100% of the cost of Long-Term Disability
coverage for all eligible employees through Cigna. st beyond the 180 day
elimination period.
The benefits under this plan are paid out at the following level:
LONG TERM DISABILITY BENEFITS
FEATURE BENEFIT
Income Replacement 60%
Monthly Maximum $12,500
Did You Know? Elimination Period 180 days
Only 5% of baby boomers
realize they have a one-in-three Maximum Benefit Period Generally, Social Security Normal Retirement Age
chance of becoming disabled Pre-existing Condition Benefits are not payable for medical conditions for which
during their working years. Limitation you incurred expenses, took prescription drugs, received
medical treatment, care or services (including diagnostic
And . . . measures), during the 12 months just prior to the most
recent effective date of insurance. Benefits are not payable
Without a paycheck, the typical
for any disability resulting from a pre-existing condition
employee’s savings lasts less unless the disability occurs after a continuous period of 12
than 5 weeks.
months without any medical treatment, care of services in
connection with the pre-existing conditions, and you have
been insured under this plan for at least 24 months after
PLEASE NOTE! your most recent effective date of insurance.
Benefits are integrated with
any amount you receive, or are
entitled to receive, under such
things as any state compulsory
benefit act or law, or Social
Security disability.
PAGE 13UNUM VOLUNTARY INSURANCE
To help cover health events from accidents to critical illness, CDU offers you
the opportunity to purchase additional policies through Unum. Should you
become injured or sick, these policies will help offset out-of-pocket medical
and indirect non-medical expenses.
VOLUNTARY ACCIDENT (w/OPTIONAL HOSPITAL RIDER)
The accident plan provides supplemental coverage to your current medical
HOW TO ENROLL plan and helps with the out-of-pocket expenses associated with accidents
and injuries, including copays, deductibles, co-insurances and other out-of-
These plans are only offered pocket expenses. Coverage is available for dependents and families as well.
during Open Enrollment. The Optional Hospital Rider helps with expenses due to hospitalization.
If you are interested in SPECIFIED CRITICAL ILLNESS (w/OPTIONAL CANCER RIDER)
enrolling in any of these plans
or desire more information Specified critical illness insurance pays a lump sum benefit up to 100% of the
about one or more of the face amount if you or a covered family member is diagnosed with a covered
plans, you will need to call: critical illness including heart attack, stroke, major organ transplant,
permanent paralysis, cancer end-stage renal failure, and coronary bypass
Unum’s Enrollment Line surgery. The benefit can be used any way you choose, and you don’t have to
(866) 961-1475 be disabled or terminally ill to receive benefits. The Optional Cancer Rider
(M-F, 5am – 5pm PST) helps with cancer treatment related expenses.
PAGE 14FLEXIBLE SPENDING ACCOUNTS
The reimbursement accounts offer you a great way to save money. These
accounts allow you to set aside pre-tax money from each paycheck to pay for
eligible out-of-pocket health care or dependent care expenses that you and
your dependents incur throughout the plan year. Budget carefully! Unused
funds are forfeited at the end of the plan year.
Since the deduction comes out of your paycheck before taxes are computed,
your taxable income is reduced. This means you pay less income tax!
IT’S EASY
You determine how much money to set aside in your account(s) for the plan
year. The amount is then subtracted in equal amounts from each paycheck
BEFORE taxes are deducted. The per-pay-period amount is then deposited
into your personal reimbursement account(s).
ENROLL EVERY YEAR!
You must re-enroll in the FSA Claims are paid once a week. When you have a health care expense not
plan every year at Open covered by our medical, dental, or vision plans, you pay the bill using your
Enrollment to continue your FSA debit card. You can also submit a claim for reimbursement manually by
FSA benefits – elections will filling out a claim form and submitting it to our plan administrator, BCC. Claim
NOT roll over year-to-year. forms are available via the BCC benefits portal.
USE IT OR LOSE IT! MAXIMUM CONTRIBUTIONS
You must use all of the money
The maximum amount you can contribute to an FSA during the plan year is:
in your FSA for eligible
expenses incurred during the • Health Care Reimbursement Account: $2,750 or IRS Annual Maximum
• Dependent Care Reimbursement Account: $5,000 or IRS Annual Maximum
plan year or forfeit it. You can
visit the fsastore.com for
Please note: If your spouse participates in a separate Dependent Care
unused funds.
Reimbursement Account, the total combined amount between both accounts
cannot exceed $5,000.
FSA ELIGIBLE EXPENSES!
An in-depth outline of FSA CLAIMS SUBMISSION DEADLINE
eligible expenses can be found
online at You have a 2½ month grace period after the end of the plan year, to incur
https://fsastore.com/FSA- additional expenses. This means you may incur expenses through March 15,
Eligibility-List.aspx. 2022.
If you have questions
regarding a potentially For the 2021 plan year, you have until March 31, 2022 to submit claims to
qualifying expense, please BCC for expenses incurred between January 1, 2021 and March 15, 2022.
contact BCC’s Customer After March 31, 2022, any unused money in either reimbursement account
Service Center at 800-685- will be forfeited, as required by the IRS.
6100.
HEALTH CARE DEPENDENT CARE ELIGIBLE EXPENSES
REIMBURSEMENT • Child care services provided inside or outside your home, but not by
ACCOUNT UPDATE! someone who is your minor child or dependent for income tax purposes
Over-the-counter medicines (for example, an older child)
are now eligible for • The child must be up to 13 years of age and must be your dependent under
reimbursement without a federal tax rules.
prescription, along with
Feminine menstrual care
products.
PAGE 15EMPLOYEE ASSISTANCE PROGRAM
Our Employee Assistance Program (EAP) through MHN will help you with a
wide spectrum of resources including Community Referrals, Legal Services,
Online Tools, and Counseling.
Community Referrals:
• Child Care
• 12-Step Groups
• Elder Care
• Academics
• Attorney Service
• Free 30-minute Phone Consultation
• Discount for services beyond the free phone consultation
• Financial Counseling
Occasionally, personal problems may arise or situations may develop that
interfere with your ability to perform your job effectively. When this occurs, it is
important to have an understanding person accessible who can offer
professional assistance. MHN is available to help you, or an eligible dependent
address life stressors that may include:
Confidentiality:
• Family or Marital Conflict
When you call and refer • Child/Adolescent Behavioral Problems
yourself into the program, it • Major Life Changes
is absolutely confidential.
• Work performance, making it hard to concentrate due to: alcohol/drug
The success of the EAP abuse; prescription drug abuse; depression; and/or financial difficulties
depends on confidentiality.
Benefits also include up to three face-to-face confidential sessions per family
Participation in the program member per problem each year – at no charge. If further help past the initial
is not documented in your sessions is necessary, the EAP can assist you in coordinating additional
employee medical or treatment through your medical plan.
personnel records and will
not affect job security or
career mobility.
EMPLOYEE ASSISTANCE PROGRAM
FREE Face-to-face Up to 3 face-to-face sessions per family member per
Counseling Sessions problem each year
24-Hour Hotline (800) 227-1060
Website https://members.mhn.com
Company Code: charlesdrew
PAGE 16OTHER BENEFITS
RETIREMENT PLANS
The University offers a Group Retirement Plan and a Supplemental Retirement
Plan. The group retirement plan is a defined contribution plan fully funded by the
University at the rate of 7% of the employee’s earning. Eligible employee must be
at least 18-years old; completed one year of continuous services with the
University and worked at least 1,000 hours.
The supplemental retirement plan is solely funded by the employee through pre-
tax payroll deduction. Employees are invited to join the supplemental retirement
plan quarterly (January 1, April 1, July 1, and October 1). Based on IRS
guideline, the maximum contribution for year 2021 is $19,500. Catch-up
contribution for age 50 or older is $6,500.
EMPLOYEE ASSISTANCE PROGRAM
The Employee Assistance Program through MHN (Managed Health Network, a
Health Net Company) provides resources to help employees and their family
members address both everyday issues as well as more serious matters
confidentially. This plan includes 24-hours Hotline assistance and 3 face-to-face
counseling sessions per year. In addition, MHN provides resources on childcare
THIS REPRESENTS ONLY A and eldercare assistance, financial, legal, identity theft recovery and daily living
SUMMARY OF BENEFITS. services. Benefit eligible employees are automatically enrolled.
DETAILS AND PLAN VACATION
DESCRIPTIONS ARE The University provides vacation time to all eligible employees. The vacation year
AVAILABLE IN THE HUMAN shall coincide with the employee’s anniversary date. Vacation benefits will begin
RESOURCES DEPARTMENT. to accrue day one of hire. The vacation accrual schedule and accrued maximum
for a full-time employee is as follows:
0-months to 5-years: 10.00 hours per month up to Maximum 180 hours
5-years and 1-month to 14-years: 13.33 hours per month up to Maximum 240
hours
14-years and 1-month and above: 16.66 hours per month up to Maximum 300
hours
SICK TIME
Beginning the first day of employment, sick leave accrues at a rate of 8-hours per
month to a maximum of 480-hours (60 days). Sick Leave can be used as it is
accrued, and can be used for the illness of the employee or to care for a sick
family member (child, spouse, or parent). It may also be used for medical or dental
appointments, including routine checkups or treatment. Sick leave will be
integrated with state disability insurance, and CDU provided short & long term
disability as appropriate.
COMMUNITY SERVICE LEAVE
Community Service Leave (CSL) is provided each calendar year to all benefits -
eligible employees working twenty (20) hours or more a week. CDU allows
employees to take up to sixteen (16) hours of leave time each calendar year with
approval of your supervisor to participate in specific approved community
volunteer activities or programs.
PAGE 17OTHER BENEFITS
LEAVE DONATION PROGRAM
The Leave Donation Program provides salary and benefits continuation for eligible
employees who have exhausted all paid leave due to their own serious illness or
injury, or due to the need to care for an immediate family member who has
experienced a catastrophic illness or injury.
LEAVES OF ABSENCE
The University complies with the State and Federal laws for provision of leaves of
absence. These include Pregnancy Disability Leave (PDL), Family and Medical
Leave Act (FMLA), California Family Rights Act (CFRA), Paid Family Leave, Parent
Time Off for School Activities, and Military Leave. For specific information regarding
eligibility for leaves of absence, please contact the Human Resources Department.
Sick leave will be integrated with state disability insurance, and CDU provided short
& long term disability as appropriate.
EDUCATION
Upon completion of 6-month introductory period, educational leave may be used to
pursue course work at an academic institution for up to 4 hours per week.
Educational leave is unpaid. Approval of educational leave is at the discretion of the
supervisor.
THIS REPRESENTS ONLY A
SUMMARY OF BENEFITS. JURY DUTY
The University encourages employees to fulfill their civic responsibilities by serving
DETAILS AND PLAN jury duty when required. All employees will receive their usual compensation for up
DESCRIPTIONS ARE to 10 days while excused from his/her work in order to satisfy jury duty obligations.
AVAILABLE IN THE HUMAN
RESOURCES DEPARTMENT. BEREAVEMENT
Bereavement leave is offered in the event of a death in the employee’s immediate
family. The paid leave is granted for three days. For services that are more than
200 miles from the employee’s home, one (1) additional day will be authorized. If
out of state travel is required to attend services, two (2) additional days will be
authorized.
LIBRARY
A free library card is available to any regular full-time employee. An employee may
use the services of the campus library during campus hours.
WORKING ADVANTAGE
A 10 million member employee shopping network allows subscribers to save up to
60% on purchases such as: Movie Passes, Broadway Shows, Theme Parks, Ski
Tickets, Sports Events, Hotels and Travel, Health and Fitness, Museums and City
Passes, Merchant Gift Certificates, Online Shopping….and much more!
PARKING
Parking is free and available on the 118th street side of the Cobb Building. A
Parking Permit will be issued by the Campus Safety Office.
Electric Car Charging Stations
Students, Faculty, Staff and Visitors have the convenience of charging their electric
vehicles in the parking lot on 118th Street, for $2.00 per hour. Currently, we have a
total of 18 charging stations.
Telecommuting Benefits
The University provides a one-time $400.00 allowance, and a monthly $50.00
allowance to employees who are required to work remotely.
PAGE 18UNIVERSITY HOLIDAYS 2021
New Year’s Day Friday, January 1, 2021
Martin Luther King Jr. Birthday Monday, January 18, 2021
(Observed)
Presidents’ Day Monday, February 15, 2021
César E. Chávez Day Wednesday, March 31, 2021
Memorial Day Monday, May 31, 2021
Juneteenth Friday, June 18, 2021
(Observed)
Independence Day Monday, July 5, 2021
(Observed)
Labor Day Monday, September 6, 2021
Veteran’s Day Thursday, November 11, 2021
Thanksgiving Day Thursday, November 25, 2021
Friday after Thanksgiving Day Friday, November 26, 2021
Christmas Eve Friday, December 24, 2021
Christmas Day Monday, December 27, 2021
(Observed)
Winter Holiday Closure Thursday, December 23, 2021 – Monday, January 3, 2022
University Holiday Schedule is subject to change at any time
PAGE 19QUESTIONS?
This guide summarizes the benefits that are available to you as an
employee of CDU.
For specific questions, please contact the Benefits Call Center (BCC)
or the benefits providers at the phone numbers listed on this page.
CARRIER/VENDOR CONTACTS
BENEFIT PROVIDER GROUP ID PHONE/WEBSITE
Medical HMO & OAMC Aetna # 120219 - HMO & OAMC (800) 445-5299 (HMO)
(877) 204-9186 (OAMC)
www.aetna.com
Medical HMO Kaiser # 227461 (800) 464-4000
www.kp.org
Dental DHMO DeltaCare USA # 75418 (800) 422-4234
www.deltadentalins.com
Dental DPPO Delta Dental of CA # 02642 (800) 765-6003
www.deltadentalins.com
Vision VSP # 00112813 (800) 877-7195
www.vsp.com
Basic Life and AD&D Cigna # FLX969287 - Life (800) 362-4462
Insurance # OK970729 - AD&D cigna.com/customer-forms
Voluntary Life Insurance Cigna # FLX969287 (800) 362-4462
www.cigna.com
Voluntary AD&D Insurance Cigna # OK970729 (800) 362-4462
www.cigna.com
Disability Insurance Cigna # LK752614 - STD (800) 362-4462
# LK966172 - LTD cigna.com/customer-forms
Unum Voluntary Insurance Unum N/A To enroll, please contact Unum’s
• Accident Enrollment Line at (866) 961-1465
• Critical Illness (Available only during open enrollment)
Flexible Spending Accounts BCC CDU (855) 230-0745, extension 6412
https://benxcel.net
Employee Assistance MHN N/A (800) 227-1060
Program https://members.mhn.com
Company Code: charlesdrew
Discount Program Working Advantage # 80566247 (800) 565-3712
www.workingadvantage.com
Discount Program Employee Savings Charles R. Drew University (310) 316-3384
Tickets www.est.us.com
Access code: ETF72G
Retirement Account TIAA-CREF # 151047 (800) 842-2252
www.tiaa-cref.com
Retirement Services & Pensionmark Charles R. Drew University (888) 201-5488
Education Retirement Group www.pensionmark.com
Benefits Call Center BCC CDU (855) 230-0745, extension 6412
https://benxcel.net PAGE 20Required Notices WOMEN’S HEALTH AND CANCER RIGHTS ACT If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: ►All states 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. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call Human Resources. INITIAL NOTICE OF YOUR HIPAA SPECIAL ENROLLMENT RIGHTS Our records show you are eligible to participate in the Charles R. Drew University of Medicine and Science Group 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 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 the Human Resources Department. NEWBORNS’ AND MOTHERS HEALTH PROTECTION ACT (NMHPA) 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 generally 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 insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). PAGE 21
PREMIUM ASSISTANCE UNDER MEDICAID AND THE
CHILDREN’S HEALTH INSURANCE PROGRAM
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 N O T 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, 2020. Contact your State for more information on
eligibility –
ALABAMA – Medicaid CALIFORNIA – Medicaid
Website: http://myalhipp.com/ Website:
Phone: 1-855-692-5447 https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_c
ont.aspx
Phone: 916-440-5676
COLORADO – Health First Colorado
ALASKA – Medicaid (Colorado’s Medicaid Program) & Child Health
Plan Plus (CHP+)
The AK Health Insurance Premium Payment Program Health First Colorado Website:
Website: http://myakhipp.com/ https://www.healthfirstcolorado.com/
Phone: 1-866-251-4861 Health First Colorado Member Contact Center:
Email: CustomerServic e@MyAKHIPP.com 1-800-221-3943/ State Relay 711
Medicaid Eligibility: CHP+ : https://www.colorado.gov/pacific/hcpf/child-
http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx health-plan-plus
CHP+ Customer Service: 1-800-359-1991/ StateRelay
711
Health Insurance Buy-In Program (HIBI) :
https://www.colorado.gov/pacific/hcpf/health-insurance-
buy-program
HIBI Customer Service: 1-855-692-6442
ARKANSAS – Medicaid FLORIDA – Medicaid
Website: http://myarhipp.com/ Website:
Phone: 1-855-MyARHIPP (855-692-7447) https://www.flmedicaidtplrecovery.com/flmedicaidtplrec
overy.com/hipp/index.html
Phone: 1-877-357-3268
PAGE 22GEORGIA – Medicaid MASSACHUSETTS – Medicaid and CHIP
Website: https://medicaid.georgia.gov/health-insurance- Website:
premium-payment-program-hipp http://www.mass.gov/eohhs/gov/departments/masshealth/
Phone: 678-564-1162 ext 2131 Phone: 1-800-862-4840
INDIANA – Medicaid MINNESOTA – Medicaid
Healthy Indiana Plan for low -income adults 19-64 Website:
Website: http://www.in.gov/fssa/hip/ https://mn.gov/dhs/people-we-serve/children-and-
Phone: 1-877-438-4479 families/health-care/health-care-programs/programs-
All other Medicaid and-services/other-insurance.jsp
Website: https://www.in.gov/medic aid/ Phone: 1-800-657-3739
Phone 1-800-457-4584
IOWA – Medicaid and CHIP (Haw ki) MISSOURI – Medicaid
Medicaid Website: Website:
https://dhs.iowa.gov/ime/members http://www.dss.mo.gov/mhd/partic ipants/pages/hipp.htm
Medicaid Phone: 1-800-338-8366 Phone: 573-751-2005
Haw ki Website:
http://dhs.iowa.gov/Hawki
Haw ki Phone: 1-800-257-8563
KANSAS – Medicaid MONTANA – Medicaid
Website: http://www.kdheks.gov/hcf/default.htm Website:
Phone: 1-800-792-4884 http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084
KENTUCKY – Medicaid NEBRASKA – Medicaid
Kentucky Integrated Health Insurance Premium Payment Website: http://www.ACCESSNebraska.ne.gov
Program (KI-HIPP) Website: Phone: 1-855-632-7633
https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Lincoln: 402-473-7000
Phone: 1-855-459-6328 Omaha: 402-595-1178
Email: KIHIPP.PROG RA M@ky .gov
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx
Phone: 1-877-524-4718
Kentucky Medicaid Website: https://chfs.ky.gov
LOUISIANA – Medicaid NEVADA – Medicaid
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Medicaid Website: http://dhcfp.nv.gov
Phone: 1-888-342-6207 (Medicaid hotline) or Medicaid Phone: 1-800-992-0900
1-855-618-5488(LaHIPP)
MAINE – Medicaid NEW HAMPSHIRE – Medicaid
Enrollment Website: Website: https://www.dhhs.nh.gov/oii/hipp.htm
https://www.maine.gov/dhhs/ofi/applic ations-forms Phone: 603-271-5218
Phone: 1-800-442-6003 Toll free number for the HIPP program:
TTY : Maine relay 711 1-800-852-3345, ext 5218
Private Health Insurance Premium Webpage:
https://www.maine.gov/dhhs/ofi/applic ations-forms
Phone: 1-800-977-6740.
TTY : Maine relay 711
PAGE 23NEW JERSEY – Medicaid and CHIP SOUTH DAKOTA - Medicaid
Medicaid Website: Website: http://dss.sd.gov
http://www.state.nj.us/humanservic es/ Phone: 1-888-828-0059
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
NEW YORK – Medicaid TEXAS – Medicaid
Website: https://www.health.ny.gov/health_care/medic aid/ Website: http://gethipptexas.com/
Phone: 1-800-541-2831 Phone: 1-800-440-0493
NORTH CAROLINA – Medicaid UTAH – Medicaid and CHIP
Website: https://medicaid.ncdhhs.gov/ Medicaid Website: https://medic aid.utah.gov/
Phone: 919-855-4100 CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
NORTH DAKOTA – Medicaid VERMONT– Medicaid
Website: http://www.nd.gov/dhs/services/medic als erv/medicaid/ Website: http://www.greenmountaincare.org/
Phone: 1-844-854-4825 Phone: 1-800-250-8427
OKLAHOMA – Medicaid and CHIP VIRGINIA – Medicaid and CHIP
Website: http://www.insureoklahoma.org Website: https://www.coverva.org/hipp/
Phone: 1-888-365-3742 Medicaid Phone: 1-800-432-5924
CHIP Phone: 1-855-242-8282
OREGON – Medicaid WASHINGTON – Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx Website: https://www.hca.wa.gov/
http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-562-3022
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid WEST VIRGINIA – Medicaid
Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medic al/ Website: http://mywvhipp.com/
HIPP- Program.aspx Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
Phone: 1-800-692-7462
RHODE ISLAND – Medicaid and CHIP WISCONSIN–Medicaid and CHIP
Website: http://www.eohhs.ri.gov/ Website:
Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-800-362-3002
SOUTH CAROLINA – Medicaid WYOMING – Medicaid
Website: https://www.scdhhs.gov Website: https://health.wyo.gov/healthcarefin/medicaid/programs-
Phone: 1-888-549-0820 and- eligibility/
Phone: 1-800-251-1269
PAGE 24T o see if any other states have added a premium assistance program since July 31, 2020, or for more information
on special enrollment rights, 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/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
PAPERWORK REDUCTION ACT STATEMENT
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 O MB 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 O MB
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 O MB 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, D C 20210 or email
ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023)
GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS
You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has
important information about your right to COBRA continuation coverage, which is a temporary extension of coverage
under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your
family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also
become eligible for other coverage options that may cost less than COBRA continuation coverage.
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 and other members
of your family when group health coverage would otherwise end. For more 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.
PAGE 25You can also read
