Required Notices

Tonkawa Tribe of Oklahoma has retained the plan of benefits that was in effect when the Affordable Care Act was passed. By maintaining a “grandfathered health plan” under the Affordable Care Act, a health plan can preserve certain basic health coverage that was already in effect when the law was enacted. Being a grandfathered health plan means your policy may not include certain consumer protections of the Affordable Care Act that apply to other plans. However, grandfathered health plans must comply withcertain other consumer protections in the Affordable Care Act. We will keep you advised as health care reform impacts our company benefits and the choices and options you may be eligibleto consider in the future. 

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Benefits Department at 580-448-3100. You may  also  contact  the  Employee  Benefits  Security  Administration,  U.S.  Department  of  Labor  at  1-866-444-3272  orwww.dol.gove/ebsa/healthreform. This website has a table summarizing which protections do and donot apply to grandfathered health plans.  

 The Health Insurance Portability and Accountability Act ("HIPAA") deals primarily with how Tonkawa Tribe of Oklahoma. can enforce eligibility and enrollment for health care benefits. Examples of some of the HIPAA requirements include: 

• Special enrollment periods are available during the year to you and your eligible dependents (in certain circumstances) that lose other health care coverage if you enroll within 31 days after losing the other health care coverage. 

• If you are not enrolled for health care coverage and add an eligible dependent (i.e. marriage), you can enroll yourself and your other eligible dependents within 31 days of the event. If you add an eligible dependent (i.e. birth, adoption or placement for adoption), you can enroll yourself and your newly acquired eligible dependents within 31 days of the event. 

The Plan will not base eligibility rules or waiting periods on any of the following factors: health status, mental or physical medical condition, and genetic information, evidence of insurability or disability. 

Evidence of insurability will not be required when health care coverage is requested during a special enrollment period or during an annual enrollment. However, the Plan may continue to provide for the exclusion of specified health conditions and apply lifetime maximums on either specific benefits or all benefits provided under the Plan.  These restrictions also do not preclude the Plan from applying differing benefit levels, benefit schedules or premium rates in certain situations as provided under HIPAA. 

In general, your annual pre-tax benefit elections are irrevocable for the plan year, January 1, 2018 through December 31, 2018. However, if you experience a Change in Status or special enrollment event that directly affects your eligibility for coverage; you may change your election within 31 days of the event.  Under limited circumstances, an election change based solely on a Change in Status must be consistent with your Change in Status (i.e. if a child is born to you, you add coverage for that child).  

Change in Status events provide more opportunities for you to make an election change than do special enrollment rights. 

If your event could be considered both a Change in Status event and a special enrollment right, you may make any change allowed by either a Change in Status or special enrollment right. 

Contact the Tonkawa Tribe of Oklahoma Benefits Department at 580-448-3100, for more information on the requirements for making an election change based on a Change in Status event or special enrollment right. 

Change in Status Events that Permit Election Changes for Health Benefits and Life Insurance Benefits: 

• Change in marital status: you may elect coverage for yourself and/or your newly acquired spouse or drop coverage for your spouse if you divorce, legally separate, have your marriage annulled or your spouse dies. 
• Change in your number of dependents: you may elect coverage for your newborn, adopted child or a child placed with you for adoption. You may drop coverage if a dependent child dies. 
• Change in employment status: you may add or drop coverage consistent with a change in employment status of you, your spouse or dependents that affect the benefit eligibility under this plan or under the employee benefit plan of your spouse or dependents. You, your spouse or dependent experience a change in employment status when any of the following occur and benefit eligibility is affected: begin or end employment, take part in a strike or lockout, begin or return from an approved leave of absence, switch from hourly to salaried, switch from union to non-union or vice versa, reduce or increase the number of hours you work or any similar change that affects your eligibility under the plan. 
• Dependent eligibility: you may add or drop your child in the event he or she becomes or ceases to be eligible under the plan. 
• Change in residence: you may change your coverage option if you move and it significantly affects your benefit availability. 

Additional Change in Status Events that Permit Election Changes for Health Benefits Only: 

• Family and Medical Leave Act (FMLA) – certain election changes are permitted when you start an FMLA leave or when you return from an FMLA leave. 
• Judgment, decree or order resulting from a divorce, legal separation, annulment or change in legal custody (including a “qualified medical child support order” or QMCSO) that requires health coverage for an Associate’s child or foster child. 
• You, your spouse or your dependent become entitled to or lose eligibility for Medicare or Medicaid. 
• You, your spouse or your dependent gain eligibility under another employer’s plan. 
• A significant change in your cost for health coverage. 
• A Change in Status that results in a “special enrollment right” under the Health Insurance Portability and Accountability Act (HIPAA). Please refer to the section below for more information. 

You must complete a Change Form and return it to the Tonkawa Tribe of Oklahoma Benefits Department within 31 days of the Change in Status. If you miss this 31 day period, you will not be able to change your coverage until the following Annual Enrollment period, unless you have another Change in Status that affects your eligibility under the plan. 

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you may be entitled to enroll in a group health plan at times other than initial eligibility or the Annual Enrollment period. You have special enrollment rights if you and/or your eligible dependents lose other group health coverage or you gain a new dependent.  If either of these events occurs, you must enroll within the 31 day time limit explained here or you will lose your special enrollment rights for that event. 

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 the medical and/or dental 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 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). 

Loss of eligibility does not include a loss of coverage that occurs because you fail to pay premiums on a timely basis, if your other coverage is terminated for cause or your voluntary termination of COBRA continuation coverage. 

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself or your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption or placement for adoption. 

You must request enrollment in the medical and/or dental plan no later than 31 days after the event giving rise to your special enrollment right, by completing and returning a new Benefit Enrollment and Change Form. If you fail to request enrollment within the 31 day time period, you and your dependents will lose the special enrollment rights for that event. 

If your special enrollment right occurs because you lost other coverage or married, your enrollment is effective on the first day of the month after your Benefits Department receives your properly completed Change Form. If your special enrollment right occurs because of a new dependent child, coverage is effective on the date of the birth, adoption or placement for adoption. 

If you or your dependent is eligible, but not enrolled, for health coverage under the Tonkawa Tribe of Oklahoma medical plan, you and/or your dependent may enroll in the plan if (i) your Medicaid or CHIP coverage is terminated as a result of loss of eligibility or (ii) you and/or your dependent become eligible for premium assistance under Medicaid or CHIP. However, to be eligible for this special enrollment opportunity, you must request coverage under the group health plan within 60 days after the date you and/or your dependent become eligible for premium assistance under Medicaid or CHIP or the date you or your dependent’s Medicaid or state-sponsored CHIP coverage ends. For more information on Medicaid and CHIP, please see the section below entitled Medicaid/CHIP. 

To request enrollment due to a special enrollment right or obtain more information, contact the Tonkawa Tribe of Oklahoma Benefits Department at 580-448-3100. 

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

If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. 

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA (3272). 

If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, 2016. You should contact your State for further information on eligibility. 

ALABAMA – Medicaid 

COLORADO – Medicaid 

Website:  http://www.medicaid.alabama.gov 580-448-3100: 1-855-692-5447 

Medicaid Website: http://www.colorado.gov/ Medicaid 580-448-3100: 1-800-221-3943 

ALASKA – Medicaid 

Website:  http://health.hss.state.ak.us/dpa/programs/medicaid/ 580-448-3100 (Outside of Anchorage): 1-888-318-8890 

580-448-3100 (Anchorage): 907-269-6529 

FLORIDA – Medicaid 

Website:    https://www.flmedicaidtplrecovery.com/ 580-448-3100: 1-877-357-3268 

GEORGIA – Medicaid 

Website: http://dch.georgia.gov/ 

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

580-448-3100: 404-656-4507 

MONTANA – Medicaid  

Website:     http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP 

580-448-3100: 1-800-694-3084 

INDIANA – Medicaid 

NEBRASKA – Medicaid 

Healthy Indiana Plan for low-income adults 19-64 

Website: 

Website: http://www.hip.in.gov 

http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebra 

580-448-3100: 1-877-438-4479 

ska_index.aspx 

580-448-3100: 1-855-632-7633 

All other Medicaid 

Website: http://www.indianamedicaid.com 

580-448-3100 1-800-403-0864 

IOWA – Medicaid 

NEVADA – Medicaid 

Website:  www.dhs.state.ia.us/hipp/ 580-448-3100: 1-888-346-9562 

Website: http://dwss.nv.gov/ 580-448-3100: 1-800-992-0900 

KANSAS – Medicaid 

Website:  http://www.kdheks.gov/hcf/ 580-448-3100: 1-785-296-3512 

KENTUCKY – Medicaid 

NEW HAMPSHIRE – Medicaid 

Website:  http://chfs.ky.gov/dms/default.htm 580-448-3100: 1-800-635-2570 

Website:  http://www.dhhs.nh.gov/oii/documents/hippapp.pdf 580-448-3100: 603-271-5218 

LOUISIANA – Medicaid 

NEW JERSEY – Medicaid and CHIP 

Website:     http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 

580-448-3100: 1-888-695-2447 

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ 

Medicaid 580-448-3100: 609-631-2392 

CHIP Website: http://www.njfamilycare.org/index.html CHIP 580-448-3100: 1-800-701-0710 

MAINE – Medicaid 

Website:     http://www.maine.gov/dhhs/ofi/public-assistance/index.html 

580-448-3100: 1-800-442-6003 

TTY: Maine relay 711 

MASSACHUSETTS – Medicaid and CHIP 

NEW YORK – Medicaid 

Website:  http://www.mass.gov/MassHealth 580-448-3100: 1-800-462-1120 

Website:  http://www.nyhealth.gov/health_care/medicaid/ 580-448-3100: 1-800-541-2831 

MINNESOTA – Medicaid 

NORTH CAROLINA – Medicaid 

Website: http://mn.gov/dhs/ma/ 580-448-3100: 1-800-657-3739 

Website:  http://www.ncdhhs.gov/dma 580-448-3100: 919-855-4100 

MISSOURI – Medicaid 

NORTH DAKOTA – Medicaid 

Website:  http://www.dss.mo.gov/mhd/participants/pages/hipp.htm 580-448-3100: 573-751-2005 

Website:     http://www.nd.gov/dhs/services/medicalserv/medicaid/ 580-448-3100: 1-844-854-4825  

Oklahoma – Medicaid and CHIP 

Utah – Medicaid and CHIP 

Website: 

http://www.insureoklahoma.org 580-448-3100: 1-888-365-3742 

Website: 

Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip 

580-448-3100: 1-877-543-7669 

Oregon - Medicaid 

Vermont - Medicaid 

Website: 

http://www.oregonhealthykids.gov  http://www.hijossaludablesoregon.gov 580-448-3100: 1-800-699-9075 

Website: 

http://www.greenmountaincare.org/ 580-448-3100: 1-800-250-8427 

Pennsylvania - Medicaid 

Virginia – Medicaid and CHIP 

Website: 

http://www.dhs.state.pa.us/hipp 580-448-3100: 1-800-692-7462 

Medicaid Website: 

http://www.coverva.org/programs_premium_assistance.  cfm Medicaid 580-448-3100: 1-800-432-5924 

CHIP Website: http://www.coverva.org/programs_premium_assistance. cfm 

CHIP 580-448-3100: 1-855-242-8282 

Rhode Island - Medicaid 

Washington - Medicaid 

Website: 

http://www.eohhs.ri.gov/ 

580-448-3100: 401-462-5300 

Website:  http://www.hca.wa.gov/medicaid/premiumpymt/pages/ 

index.aspx 

580-448-3100: 1-800-562-3022 ext. 15473 

South Carolina - Medicaid 

West Virginia - Medicaid 

Website: 

http://www.scdhhs.gov 

580-448-3100: 1-888-549-0820 

Website:  http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/ 

Pages/default.aspx 

580-448-3100: 1-877-598-5820, HMS Third Party Liability 

South Dakota - Medicaid 

Wisconsin – Medicaid and CHIP 

Website: 

http://dss.sd.gov 

580-448-3100: 1-888-828-0059 

Website: 

https://www.dhs.wisconsin.gov/badgercareplus/p-  10095.htm 580-448-3100: 1-800-362-3002 

Texas - Medicaid 

Wyoming - Medicaid 

Website: 

http://gethipptexas.com/ 

580-448-3100: 1-800-440-0493 

Website: 

https://wyequalitycare.acs-inc.com/ 580-448-3100: 307-777-7531 

To see if any more States have added a premium assistance program since January 31, 2016, or for more information on special enrollment rights, you can contact either: 

U.S. Department of LaborU.S. Department of Health and Human Services Employee Benefits Security AdministrationCenters for Medicare & Medicaid Services 

www.dol.gov/ebsawww.cms.hhs.gov 

1-866-444-EBSA (3272)1-877-267-2323, Menu Option 

4, Ext. 61565 

OMB Control Number 1210-0137 (Expires 10/31/2016)