Office of Human Resources

Introduction

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.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally does not accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your spouse dies;
• Your spouse’s hours of employment are reduced;
• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

• The parent-employee dies;
• The parent-employee’s hours of employment are reduced;
• The parent-employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the Plan as a “dependent child.”

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

• The end of employment or reduction of hours of employment;
• Death of the employee;
• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: the Office of Human Resources.

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some

of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

Have questions?

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Keep your plan informed of address changes

To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

If you are declining enrollment for yourself or your dependents (including your spouse) because of other

health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards 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).

If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

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.

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 obtain more information, contact the Human Resources department.

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).

Women’s Health and Cancer Rights ActIf 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 stages of reconstruction of the breast on which the mastectomy was performed;
• surgery and reconstruction of the other breast to produce a symmetrical appearance;
• prostheses; 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.

HMO plans generally require the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Harvard Pilgrim Health Care at 888-333-4742.

For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from Harvard Pilgrim Health Care or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization services, following a pre- approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Harvard Pilgrim Health Care at 888-333-4742.

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).

• Alabama – Medicaid
  • Website: https://www.myalhipp.com/
  • Phone: 1-855-692-5447
• Georgia – Medicaid
  • Website: https://medicaid.georgia.gov/ (Click on Health Insurance Premium Payment (HIPP))
  • Phone: 404-656-4507
• Alaska – Medicaid
  • Website: https://health.alaska.gov/dpa/Pages/medicaid/default.aspx
  • Phone (Outside of Anchorage): 1-888-318-8890
  • Phone (Anchorage): 907-269-6529
• Indiana – Medicaid
  • Healthy Indiana Plan for low-income adults 19- 64
    • Website: https://www.in.gov/fssa/hip/
    • Phone: 1-877-438-4479
  • All other Medicaid
    • Website: https://www.in.gov/medicaid/ 
    • Phone 1-800-403-0864
• Colorado – Medicaid
  • Medicaid Website: https://hcpf.colorado.gov/ 
  • Medicaid Customer Contact Center: 1-800-221- 3943
• Iowa  – Medicaid
  • Website: https://hhs.iowa.gov/programs/welcome-iowa-medicaid 
  • Phone: 1-888-346-9562
• Florida – Medicaid
  • Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html 
  • Phone: 1-877-357-3268
• Kansas – Medicaid
  • Website: https://www.kancare.ks.gov/ 
  • Phone: 1-785-296-3512
• Kentucky – Medicaid
  • Website: https://www.chfs.ky.gov/agencies/dms/Pages/default.aspx
  • Phone: 1-800-635-2570
• New Hampshire – Medicaid
  • Website: https://www.dhhs.nh.gov/programs-services/medicaid 
  • Phone: 603-271-5218
• Louisiana – Medicaid
  • Website: https://ldh.la.gov/index.cfm/subhome/1/n/33%201 
  • Phone: 1-888-695-2447
• New Jersey – Medicaid and CHIP
  • Medicaid Website: https://www.nj.gov/humanservices/dmahs/clients/medicaid/ 
  • Medicaid Phone: 609-631-2392
• Maine – Medicaid 
  • Website: https://www.maine.gov/dhhs/ofi/programs-services/health-care-assistance 
  • Phone: 1-800-442-6003
  • TTY: Maine relay 711
• New York – Medicaid
  • Website: https://www.health.ny.gov/health_care/medicaid/ 
  • Phone: 1-800-541-2831
• Massachusetts – Medicaid and CHIP
  • Website: https://www.mass.gov/orgs/masshealth 
  • Phone: 1-800-462-1120
• North Carolina – Medicaid
  • Website: https://medicaid.ncdhhs.gov/ 
  • Phone: 919-855-4100
• Minnesota – Medicaid
  • Website: https://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/medical-assistance.jsp 
  • Phone: 1-800-657-3739
• North Dakota – Medicaid
  • Website: https://www.hhs.nd.gov/healthcare/medicaid 
  • Phone: 1-844-854-4825
• Missouri – Medicaid
  • Website: https://mydss.mo.gov/mhd/healthcare 
  • Phone: 573-751-2005
• Oklahoma – Medicaid
  • Website: https://oklahoma.gov/ohca/insureoklahoma.html 
  • Phone: 1-888-365-3742
• Montana – Medicaid
  • Website: https://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP 
  • Phone: 1-800-694-3084
• Oregon – Medicaid
  • Website: https://www.oregon.gov/oha/hsd/ohp/pages/ohpcoversme.aspx and https://www.oregon.gov/oha/HSD/OHP/Pages/OHPesparami.aspx 
  • Phone: 1-800-699-9075
• Nebraska – Medicaid
  • Website: https://dhhs.ne.gov/Pages/Medicaid-Eligibility.aspx 
  • Phone: 1-855-632-7633
• Pennsylvania – Medicaid
  • Website: https://www.pa.gov/en/services/dhs/apply-for-medicaid-health-insurance-premium-payment-program-hipp.html 
  • Phone: 1-800-692-7462
• Nevada – Medicaid
  • Medicaid Website: https://dwss.nv.gov/ 
  • Phone: 1-800-992-0900
• Rhode Island – Medicaid
  • Website: https://eohhs.ri.gov/ 
  • Phone: 401-462-5300
• South Carolina – Medicaid
  • Website: https://www.scdhhs.gov/ 
  • Phone: 1-888-549-0820
• Virginia – Medicaid and CHIP
  • https://coverva.dmas.virginia.gov/learn/premium-assistance/ 
  • Medicaid Phone: 1-800-432-5924
  • CHIP Website: https://coverva.dmas.virginia.gov/learn/premium-assistance/  
  • CHIP Phone: 1-855-242-8282
• South Dakota
  • Website: https://dss.sd.gov/ 
  • Phone: 1-888-828-0059
• Washington – Medicaid
  • Website: https://www.hca.wa.gov/free-or-low-cost-health-care/i-help-others-apply-and-access-apple-health/premium-payment-program 
  • Phone: 1-800-562-3022 ext. 15473
• Texas – Medicaid
  • Website: https://www.hhs.texas.gov/services/financial/health-insurance-premium-payment-hipp-program 
  • Phone: 1-800-440-0493
• West Virginia – Medicaid 
  • Website: https://dhhr.wv.gov/bms/Pages/default.aspx 
  • Phone: 1-877-598-5820, HMS Third Party Liability
• Utah – Medicaid and CHIP
  • Website: http://health.utah.gov/medicaid CHIP: https://medicaid.utah.gov/ 
  • Phone: 1-877-543-7669
• Wisconsin – Medicaid and CHIP
  • Website: https://www.dhs.wisconsin.gov/medicaid/index.htm 
  • Phone: 1-800-362-3002
• Vermont – Medicaid 
  • Website: https://dvha.vermont.gov/members 
  • Phone: 1-800-250-8427
• Wyoming – Medicaid
  • Website: https://health.wyo.gov/healthcarefin/medicaid/ 
  • Phone: 307-777-7531

To see if any other states have added a premium assistance program since January 31, 2021, 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,  https://www.cms.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 12/31/2023)

The Brandeis Healthy You program is a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary wellbeing assessment that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You also have the option to submit biometric results you receive from your primary care physician, which may include total cholesterol, HDL, TC/HDL ratio, glucose, blood pressure, height, weight, BMI, and waist circumference. You are not required to complete the wellbeing assessment or submit your biometric results. 

Employees who choose to participate in the wellness program are eligible to win raffle prizes for achieving 20, 40, 60, and 80+ points on the Harvard Pilgrim Health Care wellness platform. You are not required to complete the wellbeing assessment or submit your biometric results in order to receive this incentive.

If you are unable to participate in any of the health-related activities required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. Through the Brandeis Healthy You program, many reasonable alternatives are available or you may print a medical waiver for your doctor to review. In the event this is inadequate, you may request a reasonable accommodation or an alternative standard by contacting Marianne Pick at mpick@brandeis.edu.

The information from your wellbeing assessment will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as suggesting health resources and setting goals. You also are encouraged to share your results or concerns with your own doctor.

We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and Brandeis Healthy You may use aggregate information it collects to design a program based on identified health risks in the workplace, Brandeis Healthy You

will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements.

In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision.

Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Marianne Pick at mpick@brandeis.edu.

If you have questions regarding the information contained in these notices call Brandeis University’s Human Resources Department at 781-736-4474.