BENEFITS 2021 - Gold's Gym Tennessee
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2021 BENEFITS OVERVIEW
WHAT’S INSIDE
This guide is designed to provide a general overview
of your benefits at Gold’s Gym Tennessee. It is not
a contract or an official interpretation of the benefit Medical Benefits...................................................... 3
plans. For more detailed information, please refer
to your summary plan descriptions or the legal
plan documents. Medical Benefits Chart............................................ 3
Should any questions or conflicts arise, the
plan documents will be the final authority in
determining your benefits. Gold’s Gym reserves Dental Benefits........................................................ 4
the right to modify or discontinue the plans at any
time. This document was prepared exclusively for
full-time employees of Gold’s Gym. Unauthorized Vision Benefits ........................................................ 4
reproduction is strictly prohibited.
Please contact Human Resources if you have any
questions regarding your benefits plan. Basic Life & AD&D .................................................. 5
ENROLLMENT CHANGES
Changes to your enrollment may be made Voluntary Life & AD&D ........................................... 5
annually during open enrollment each year. Mid-
year changes may be made for the following
qualifying events such as marriage/divorce, birth/
adoption, death, change in job status of yourself Annual Notices................................................... 6-12
or your spouse, and or change in Medicaid/CHIP
eligibility.
However, all changes must be made within 30 days
(with the exception of Medicaid/CHIP which gives you
up to 60 days) of your qualifying event. You must notify
Human Resources immediately when you experience a
qualifying event.
SECTION 125 PLAN PREMIUM CONVERSION
Section 125 Premium Conversion Plan lets you exclude
your Medical, Dental and Vision premiums from your
taxable income, meaning your premiums will come
out of your income pre-tax. This lowers your taxable
income. By default, your premiums will be deducted
pre-tax, increasing your take-home pay anywhere
from a couple hundred dollars to a thousand or more
annually.
You may elect to have your premiums deducted after-
tax. If you wish to have your premiums deducted after-
tax, please see Human Resources.
If you (and/or your dependents) 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 the Annual Notices for more details.
2
MEDICAL BENEFITS
Hum ana | 1 -800-4 5 7 -4708 | w ww. h u ma n a . c o m | G ro u p Nu mb e r: S e e I D C a r d
Gold’s Gym’s medical benefits are provided through
SEMI-MONTHLY
Humana. HDHP PPO
PREMIUMS
Gold’s Gym offers plan options in the Humana Employee Only $37.84 $74.02
ChoicePOS Network. In this network, you have
Employee + Spouse $142.75 $222.84
the flexibility to go to any provider that you choose;
however, anytime you select an in-network physician Employee + Child(ren) $116.40 $185.63
or facility, you will see significant discounts and Employee + Family $213.03 $322.05
savings.
If you select an out-of-network physician or facility, you will be subject to higher deductibles and out-of-pocket
maximums. You are also responsible for the difference between billed charges and the maximum allowable
charge. It definitely works to your advantage to go in network whenever possible.
To find an in-network provider near you, go to www.humana.com and click on “Find A Doctor.” Please be sure
to consult either the online directory or the Humana customer service department to confirm that your provider
participates in the network.
HDHP Plan PPO Plan
MEDICAL BENEFITS*
In-Network In-Network
Deductible: Individual / Family $5,000 / $10,000 $2,500 / $5,000
Out-of-Pocket Maximum: Individual / Family $6,350 / $12,700 $5,000 / $10,000
Covered Services Overview
Preventive Care Covered 100% Covered 100%
Office Visit - Primary Care Physicians 20% after deductible $30 copay
Office Visit - Specialists 20% after deductible $55 copay
Telemedicine $51 charge $30 copay
Urgent Care 20% after deductible $55 copay
Emergency Room 20% after deductible $350 copay
Most Other Services 20% after deductible 50% after deductible
PHARMACY - Retail Network
Generic 20% after deductible $10 copay
Preferred Brand 20% after deductible $40 copay
Non-Preferred Brand 20% after deductible $70 copay
Specialty (Self-Administered) 20% after deductible 25%
*Review plan documents for out-of-network rates, prior authorization requirements, limits on the number of visits per year and service restrictions.
3
DENTAL BENEFITS
Hum ana | 1 -877-8 7 7 -1051 | w ww. h u ma n a . c o m | G ro u p Nu mb e r: S e e I D C a r d
Your dental benefits at Gold’s Gym are provided by Humana. This
dental plan is a PPO (similar to your medical plan), in that you may SEMI-MONTHLY PREMIUMS
visit any provider that you choose, however, you will most likely see
increased benefit levels if you go to a provider in network. Employee Only $14.60
Employee + Spouse $29.19
DENTAL BENEFITS In-Network Employee + Child(ren) $43.08
Deductible: (Aggregate) Employee + Family $59.06
$50 / $150
Individual / Family
Benefits Paid by the Plan To find a provider in the network, visit
www.humana.com and click on “Find A
Calendar Year Maximum $1,000 Doctor.”
Preventive (x-rays, exams,
100%
cleanings)
Basic (endo, periodontic
80%
services, oral surgery)
Major - (restorative,
50%
prosthodontics, implants)
50% to $1,000
Orthodontia
(for children and adults)
VISION BENEFITS
Hum ana | 1 -877-8 7 7 -1051 | w ww. h u ma n a . c o m | G ro u p Nu mb e r: S e e I D C a r d
Your vision plan is provided by Humana. When using in-network
providers, this PPO plan covers most exams, eyeglass and medically SEMI-MONTHLY PREMIUMS
necessary contacts in full. Discounts are available for upgrades on
covered frames and lenses, as well. Humana has also partnered Employee Only $2.96
with several refractive eye surgery centers to offer discounts to its Employee + Spouse $5.93
members. Employee + Child(ren) $5.63
Employee + Family $8.85
VISION BENEFITS In-Network
Vision Exam To find an in-network provider or surgery
Every 12 months
$10 copay center, call customer service or go to www.
Prescription Glasses $25 materials copay humana.com and click on “Find a Doctor.”
Frames $100 allowance Should you choose to see an out-of-
Every 24 months network provider, Humana will reimburse
Standard Lenses (Single, Bifocal, you up to a specified amount. Please see
Trifocal) 100% after copay the plan document for the out-of-network
Every 12 months reimbursement schedule.
Contact Lenses (instead of glasses) $100 allowance
Standard Contact Lens Fit & Follow Up $40 copay
Premium Contact Lens Fit & Follow Up 10% off retail price
4
BASIC LIFE AND AD&D
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At Gold’s Gym, Basic Life/Accidental Death and Dismemberment (AD&D) Insurance is a provided benefit at no
cost to you through Humana. The coverage amount is $10,000.
AD&D insurance pays an additional amount based on a specific list of losses such as loss of life, limb, or sight
due to an accident. Please remember to contact Human Resources when you need to update your beneficiaries.
The benefit reduces by 35% at age 65, 50% at age 70 and terminates at Retirement.
VOLUNTARY LIFE AND AD&D
Hum ana | 1 -888-3 4 7 -0092 | w ww. h u ma n a . c o m | G ro u p Nu mb e r: S e e I D C a r d
Voluntary Life Insurance is available for you Employee Rate Spouse Rate
and your dependents through Humana. This Age Band
Per $1,000 per $1,000
voluntary coverage is paid for entirely by you.
0-24 $0.06 $0.06
You may purchase coverage in $1,000 25-29 $0.06 $0.06
increments up to $100,000. The first $100,000 30-34 $0.07 $0.06
may be purchased without evidence of good
35-39 $0.10 $0.09
health.
40-44 $0.15 $0.13
For your spouse, you may purchase increments 45-49 $0.23 $0.20
of $1,000 to a maximum of $50,000. You may
50-54 $0.36 $0.31
not purchase more than 50% of life insurance
coverage for your spouse than the amount you 55-59 $0.58 $0.50
purchased for yourself. The first $50,000 may be 60-64 $0.81 $0.70
purchased without evidence of good health. 65-69 $1.34 $1.16
For your dependent child age 14 days to 26 70-74 $2.61 $2.26
years, you may select $10,000 of coverage. You 75-79 $5.04 $4.37
pay $2.00 per month for $10,000 in coverage, 80-999 $9.41 $8.15
regardless of how many children you have.
The full $10,000 can be purchased without any
Child Rate
medical approval questionnaire. $2.00
(per $10,000)
This benefit reduces by 35% at age 65 and 50%
at age 70. AD&D $0.03 $0.03
Rates for voluntary life coverage are based on
your age and can be seen in the chart here.
Please remember to contact Human Resources when you need to update your beneficiaries.
5
ANNUAL NOTICES
IMPORTANT NOTICES FROM OUR including lymphedema. not in excess of 48 hours (or 96 hours).
COMPANY REGARDING THE PLAN These benefits will be provided Refer to your plan document for specific
The following notices provide important subject to the same deductibles and information about childbirth coverage or
information about the group health plan coinsurance applicable to other medical contact your plan administrator.
provided by your employer. Please read and surgical benefits provided under For additional information about NMHPA
the attached notices carefully and keep this plan. provisions and how Self-funded non
a copy for your records. If you would like more information on Federal governmental plans may opt-
If you have any questions regarding WHCRA benefits, contact your Health out of the NMHPA requirements, visit
any of these notices, please contact: Insurance issuer. http://www.cms.gov/CCIIO/Programs-
and-Initiatives/Other-Insurance-
Gold’s Gym Tennessee MASTECTOMY NOTICE Protections/nmhpa_factsheet.html.
Contact: Jennifer Staiman Patients who undergo a mastectomy
Phone: 865-288-4943 HIPAA NOTICE OF PRIVACY
and who elect breast reconstruction in PRACTICES
Mailing Address: 10708 Kingston Pike connection with the mastectomy are
Knoxville, TN 37934 entitled to coverage for: The Health Insurance Portability and
Distribution Date: December 2020 Accountability Act of 1996 (“HIPAA”)
• Reconstruction of the breast on which requires that we maintain the privacy
UNIFORMED SERVICES the mastectomy was performed;
EMPLOYMENT AND of protected health information, give
REEMPLOYMENT RIGHTS • Surgery and reconstruction of the notice of our legal duties and privacy
ACT OF 1994 other breast to produce a symmetrical practices regarding health information
appearance; and about you and follow the terms of our
A Subscriber may continue his or her notice currently in effect.
coverage and coverage for his or • Prostheses and treatment of physical
her Dependents during military leave complications at all stages of the If not attached to this document, you
of absence in accordance with the mastectomy, including lymphedemas may request a copy of the current
Uniformed Services Employment and Privacy Practices, explaining how
In a manner determined in consultation
Reemployment Rights Act of 1994. medical information about you may be
with the attending physician and the
When the Subscriber returns to work used and disclosed and how you can
patient. The coverage may be subject
from a military leave of absence, the get access to this information.
to coinsurance and deductibles
Subscriber will be given credit for the consistent with those established for As Required by Law. We will disclose
time the Subscriber was covered under other benefits. Health Information when required to
the Plan prior to the leave. do so by international, federal, state or
Please contact Human Resources for
WOMEN’S HEALTH AND CANCER local law.
more information.
RIGHTS ACT NOTICE You have the right to inspect and copy,
NEWBORNS’ AND MOTHERS’
If you have had or are going to have right to an electronic copy of electronic
HEALTH PROTECTION ACT
a mastectomy, you may be entitled to medical records, right to get notice
Newborns’ and Mothers’ Health of a breach, right to amend, right to
certain benefits under the Women’s
Protection Act requires that group health an accounting of disclosures, right to
Health and Cancer Rights Act of 1998
plans and health insurance issuers who request restrictions, right to request
(WHCRA). If you have had or are going to
offer childbirth coverage generally may confidential communications, right to a
have a mastectomy, you may be entitled
not, under federal law, restrict benefits paper copy of this notice and the right
to certain benefits. For individuals
for any hospital length of stay in to file a complaint if you believe your
receiving mastectomy-related benefits,
connection with childbirth for the mother privacy rights have been violated.
coverage will be provided in a manner
or newborn child to less than 48 hours
determined in consultation with the NOTICE OF SPECIAL ENROLLMENT
following a vaginal delivery, or less than
attending physician and the patient, for: RIGHTS TO NEW ENROLLEES
96 hours following a cesarean section.
• All stages of reconstruction of However, federal law generally does If you are declining enrollment for
the breast on which the mastectomy not prohibit the mother’s or newborn’s yourself or your dependents (including
was performed; attending provider, after consulting your spouse) because of other health
• Surgery and reconstruction with the mother, from discharging the insurance or group health plan
of the other breast to produce a mother or her newborn earlier than 48 coverage, you may be able to enroll
symmetrical appearance; hours (or 96 hours as applicable). In any yourself and your dependents in this
case, plans and issuers may not, under plan if you or your dependents lose
• Prostheses; and federal law, require that a provider eligibility for that other coverage (or
• Treatment of physical obtain authorization from the plan or the if the employer stops contributing
complications of the mastectomy, issuer for prescribing a length of stay toward your or your dependents’ other
6
coverage). However, you must request covered under the Plan that we comply treatment purposes. Your physician
enrollment within 30 days after your or with federal privacy laws and respect or health care provider is required to
your dependents’ other coverage ends your right to privacy. Our Company provide you with an explanation of
(or after the employer stops contributing requires all members of our workforce how they use and share your health
toward the other coverage). In addition, and third parties that are provided information for purposes of treatment,
if you have a new dependent as a access to protected health information payment, and health care operations.
result of marriage, birth, adoption, or to comply with the privacy practices As permitted or required by law. We may
placement for adoption, you may be able outlined below. also use or disclose your protected
to enroll yourself and your dependents. Protected Health Information health information without your written
However, you must request enrollment authorization for other reasons as
within 30 days after the marriage, birth, Your protected health information is
protected by the HIPAA Privacy Rule. permitted by law. We are permitted
adoption, or placement for adoption. by law to share information, subject
Generally, protected health information
If you are decline enrollment for is information that identifies an individual to certain requirements, in order to
yourself or your dependents (including created or received by a health care communicate information on health-
your spouse) while coverage under provider, health plan or an employer related benefits or services that may
Medicaid or a state Children’s Health on behalf of a group health plan that be of interest to you, respond to a
Insurance Program (CHIP) is in effect, relates to physical or mental health court order, or provide information to
you may be able to enroll yourself and conditions, provision of health care, or further public health activities (e.g.,
your dependents in this plan if you or payment for health care, whether past, preventing the spread of disease)
your dependents lose eligibility for that present or future. without your written authorization. We
other coverage. However, you must are also permitted to share protected
request enrollment within 60 days after How We May Use Your Protected Health health information during a corporate
your or your dependents’ Medicaid or Information restructuring such as a merger, sale, or
CHIP coverage ends. If you or your Under the HIPAA Privacy Rule, we may acquisition. We will also disclose health
dependents (including your spouse) use or disclose your protected health information about you when required
become eligible for a state premium information for certain purposes without by law, for example, in order to prevent
assistance subsidy from Medicaid or a your permission. This section describes serious harm to you or others.
CHIP program with respect to coverage the ways we can use and disclose your Pursuant to your Authorization. When
under this plan, you may be able to enroll protected health information. required by law, we will ask for your
yourself and your dependents (including
Payment. We use or disclose your written authorization before using
your spouse) in this plan. However, you
protected health information without or disclosing your protected health
must request enrollment within 60 days
your written authorization in order to information. If you choose to sign an
after you or your dependents become
determine eligibility for benefits, seek authorization to disclose information,
eligible for the premium assistance.
reimbursement from a third party, or you can later revoke that authorization to
To request special enrollment or obtain coordinate benefits with another health prevent any future uses or disclosures.
more information, contact the plan’s plan under which you are covered. For To Business Associates. We may enter
General Contact. example, a health care provider that into contracts with entities known as
PLEASE REVIEW IT CAREFULLY. provided treatment to you will provide Business Associates that provide
us with your health information. We use services to or perform functions on
Our Company’s Pledge to You that information in order to determine behalf of the Plan. We may disclose
This notice is intended to inform you whether those services are eligible for protected health information to Business
of the privacy practices followed by payment under our group health plan. Associates once they have agreed
the Our Company Health and Welfare Health Care Operations. We use in writing to safeguard the protected
Plan (the Plan) and the Plan’s legal and disclose your protected health health information. For example, we
obligations regarding your protected information in order to perform plan may disclose your protected health
health information under the Health administration functions such as information to a Business Associate to
Insurance Portability and Accountability quality assurance activities, resolution administer claims. Business Associates
Act of 1996 (HIPAA). The notice also of internal grievances, and evaluating are also required by law to protect
explains the privacy rights you and your plan performance. For example, we protected health information. To the
family members have as participants of review claims experience in order to Plan Sponsor. We may disclose
the Plan. It is effective in April. [Note: the understand participant utilization and protected health information to certain
effective date may not be earlier than to make plan design changes that are employees of Our Company for the
the date on which the privacy notice is intended to control health care costs. purpose of administering the Plan.
printed or otherwise published]. These employees will use or disclose
Treatment. Although the law allows use
The Plan often needs access to your the protected health information
and disclosure of your protected health
protected health information in order to only as necessary to perform plan
information for purposes of treatment,
provide payment for health services and administration functions or as otherwise
as a health plan we generally do not
perform plan administrative functions. required by HIPAA, unless you have
need to disclose your information for
We want to assure the plan participants authorized additional disclosures. Your
7protected health information cannot be charge within a 12-month period. Our Legal Responsibilities
used for employment purposes without Right to Request Restrictions. You have We are required by law to protect
your specific authorization. the right to request that we not use the privacy of your protected health
Your Rights or disclose information for treatment, information, provide you with certain
Right to Inspect and Copy. In most cases, payment, or other administrative rights with respect to your protected
you have the right to inspect and copy purposes except when specifically health information, provide you with this
the protected health information we authorized by you, when required by notice about our privacy practices, and
maintain about you. If you request law, or in emergency circumstances. follow the information practices that are
copies, we will charge you a reasonable You also have the right to request that described in this notice.
fee to cover the costs of copying, mailing, we limit the protected health information We may change our policies at any
or other expenses associated with your that we disclose to someone involved in time. In the event that we make a
request. Your request to inspect or your care or the payment for your care, significant change in our policies, we
review your health information must be such as a family member or friend. will provide you with a revised copy
submitted in writing to the person listed Your request for restrictions must be of this notice. You can also request a
below. In some circumstances, we may submitted in writing to the person listed copy of our notice at any time. For more
deny your request to inspect and copy below. We will consider your request, but information about our privacy practices,
your health information. To the extent in most cases are not legally obligated contact the person listed below. If you
your information is held in an electronic to agree to those restrictions. However, have any questions or complaints,
health record, you may be able to we will comply with any restriction please contact: Human Resources.
receive the information in an electronic request if the disclosure is to a health PATIENT PROTECTION
format. plan for purposes of payment or health DISCLOSURE
Right to Amend. If you believe that care operations (not for treatment)
and the protected health information Our Company generally allows the
information within your records is designation of a primary care provider.
incorrect or if important information is pertains solely to a health care item or
service that has been paid for out-of- You have the right to designate any
missing, you have the right to request primary care provider who participates
that we correct the existing information pocket and in full.
in our network and who is available to
or add the missing information. Right to Request Confidential accept you or your family members.
Your request to amend your health Communications. You have the right to For information on how to select a
information must be submitted in receive confidential communications primary care provider, and for a list of
writing to the person listed below. containing your health information. the participating primary care providers,
In some circumstances, we may Your request for restrictions must be contact our medical provider, listed on
deny your request to amend your submitted in writing to the person listed the medical benefits page herein.
health information. If we deny your below. We are required to accommodate
request, you may file a statement of reasonable requests. For example, For children, you may designate
disagreement with us for inclusion in you may ask that we contact you at a pediatrician as the primary care
any future disclosures of the disputed your place of employment or send provider.
information. communications regarding treatment to
You do not need prior authorization from
Right to an Accounting of Disclosures. You an alternate address. Our Company or from any other person
(including a primary care provider) in
have the right to receive an accounting Right to be Notified of a Breach. You have
order to obtain access to obstetrical
of certain disclosures of your protected the right to be notified in the event that
health information. The accounting will we (or one of our Business Associates) or gynecological care from a health
not include disclosures that were made discover a breach of your unsecured care professional in our network who
(1) for purposes of treatment, payment protected health information. Notice specializes in obstetrics or gynecology.
or health care operations; (2) to you; of any such breach will be made in The health care professional, however,
(3) pursuant to your authorization; accordance with federal requirements. may be required to comply with certain
procedures, including obtaining prior
(4) to your friends or family in your Right to Receive a Paper Copy of this Notice.
presence or because of an emergency; If you have agreed to accept this notice authorization for certain services,
(5) for national security purposes; or electronically, you also have a right tofollowing a pre-approved treatment
(6) incidental to otherwise permissible obtain a paper copy of this notice fromplan, or procedures for making referrals.
disclosures. For a list of participating health care
us upon request. To obtain a paper professionals who specialize in
Your request to for an accounting must copy of this notice, please contact the obstetrics or gynecology, contact our
be submitted in writing to the person person listed below. medical provider, listed on the
listed below. You may request an medical benefits page herein.
accounting of disclosures made
within the last six years. You may
request one accounting free of
4823 Old Kingston Pike, Suite 300, Knoxville, TN 37919
(865) 531-9898 • www.trinityben.com
Produced and Printed by Trinity Companies, 12/2020
8Important Notice About Your Prescription Drug Coverage and Medicare
If you or any of your eligible dependents are eligible for Medicare, or will soon become eligible
for Medicare, please read this notice. If not, you can disregard this notice.
Please read this notice carefully and keep it where you can find it. This notice has information
about your current prescription drug coverage under the health plan 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. We have determined that the prescription drug coverage offered by the health plan is,
on average for all plan participants, expected to pay out as much as standard Medicare
prescription drug coverage pays and is therefore considered Creditable Coverage.
Because your existing coverage is Creditable Coverage, you can keep this coverage and not
pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from
October 15th to December 7th. However, if you lose your current creditable prescription drug coverage,
through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period
(SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug
Plan?
If you decide to join a Medicare drug plan, your current coverage [will or will not] be affected.
Prescription Drug Benefits
HDHP Plan PPO Plan
for HDHP and PPO Plans
Generic 20% after deductible $10 copay
Preferred Brand 20% after deductible $40 copay
Non-Preferred Brand 20% after deductible $70 copay
Specialty 20% after deductible 25%
Contact your plan administrator for an explanation of the prescription drug coverage plan provisions/
options under the plan available to Medicare eligible individuals when you become eligible for Medicare
Part D. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you
and your dependents [may or may not] be able to get this coverage back.
9When 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 health plan coverage and don’t join a
Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher
premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly
premium may go up by at least 1% of the Medicare base beneficiary premium per month for every
month that you did not have that coverage. For example, if you go nineteen months without creditable
coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary
premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription
drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice or Your Current Prescription Drug Coverage
please contact the plan administrator indicated on the first page of this notice.
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 your current health plan provided by the current insurer 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: 1/1/2021
Name of Entity/Sender Gold’s Gym Tennessee
Contact -- Position / Office: Jennifer Staiman - Human Resources Manager
Address: 10708 Kingston Pike
Knoxville, TN 37934
Phone: 865-288-4943
10Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance
program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t
be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more
information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if
premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these
programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your
state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you
to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of
being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at
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: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx
Phone: 1-855-692-5447 Phone: 916-440-5676
ALASKA – Medicaid COLORADO – Health First Colorado
(Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)
The AK Health Insurance Premium Payment Program Website: Health First Colorado Website: https://www.healthfirstcolorado.com/
http://myakhipp.com/ Health First Colorado Member Contact Center:
Phone: 1-866-251-4861 1-800-221-3943/ State Relay 711
Email: CustomerService@MyAKHIPP.com CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx CHP+ Customer Service: 1-800-359-1991/ State Relay 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: https://www.flmedicaidtplrecovery.com/flmedicaidtplrec
Phone: 1-855-MyARHIPP (855-692-7447) overy.com/hipp/index.html
Phone: 1-877-357-3268
GEORGIA – Medicaid MASSACHUSETTS – Medicaid and CHIP
Website: https://medicaid.georgia.gov/health-insurance- premium-payment- Website: http://www.mass.gov/eohhs/gov/departments/masshealth
program-hipp Phone: 1-800-862-4840
Phone: 678-564-1162 ext 2131
INDIANA – Medicaid MINNESOTA – Medicaid
Healthy Indiana Plan for low-income adults 19-64 Website: https://mn.gov/dhs/people-we-serve/children-and-families/health-
Website: http://www.in.gov/fssa/hip/ care/health-care-programs/programs- and-services/other-insurance.jsp
Phone: 1-877-438-4479 Phone: 1-800-657-3739
All other Medicaid
Website: https://www.in.gov/medicaid/
Phone 1-800-457-4584
IOWA – Medicaid and CHIP (Hawki) MISSOURI – Medicaid
Medicaid Website: https://dhs.iowa.gov/ime/members Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Medicaid Phone: 1-800-338-8366 Phone: 573-751-2005
Hawki Website: http://dhs.iowa.gov/Hawki
Hawki Phone: 1-800-257-8563
KANSAS – Medicaid MONTANA – Medicaid
Website: http://www.kdheks.gov/hcf/default.htm Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Phone: 1-800-792-4884 Phone: 1-800-694-3084
KENTUCKY- Medicaid NEBRASKA – Medicaid
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: http://www.ACCESSNebraska.ne.gov
Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-632-7633
Phone: 1-855-459-6328 Lincoln: 402-473-7000
Email: KIHIPP.PROGRAM@ky.gov Omaha: 402-595-1178
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 1-855-618- 5488 (LaHIPP) Medicaid Phone: 1-800-992-0900
11MAINE – Medicaid NEW HAMPSHIRE – Medicaid
Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Website: https://www.dhhs.nh.gov/oii/hipp.htm
Phone: 1-800-442-6003 Phone: 603-271-5218
TTY: Maine relay 711 Toll free number for the HIPP program: 1-800-852-3345, ext 5218
Private Health Insurance Premium Webpage:
https://www.maine.gov/dhhs/ofi/applications-forms
Phone: 1-800-977-6740.
TTY: Maine relay 711
NEW JERSEY – Medicaid and CHIP SOUTH DAKOTA - Medicaid
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Website: http://dss.sd.gov
Medicaid Phone: 609-631-2392 Phone: 1-888-828-0059
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/medicaid/ 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://medicaid.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/medicalserv/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/Medical/HIPP- Website: http://mywvhipp.com/
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: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) Phone: 1-800-362-3002
SOUTH CAROLINA – Medicaid WYOMING – Medicaid
Website: https://www.scdhhs.gov Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-
Phone: 1-888-549-0820 eligibility/
Phone: 1-800-251-1269
To 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 OMB 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 OMB 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 OMB
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, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023)
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