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Important Legal Notices Special Enrollment Provision Name&Title—Adalia Medina-Graham Loss of Other Coverage(Except Medicaid or a State Children's Health Office—Human Resources,FMLA Insurance Program). If you decline enrollment for yourself or for an Address-6500 57th Street,Vero Beach,FL 32967 eligible dependent (including your spouse) while other health Phone-772-564-3001 insurance or group health plan coverage is in effect,you may be able to Email -adalia.medina-graham@indianriverschools.org enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage(or if the employer You can file a grievance in person or by mail,fax,or email. If you stops contributing toward your or your dependents' other coverage). need help filing a grievance,Adalia Medina-Graham is available to However, you must request enrollment within 31 days after your or help you. your dependents' other coverage ends (or after the employer stops You can also file a civil rights complaint with the U.S.Department of contributing toward the other coverage). Health and Human Services, Office for Civil Rights, electronically Loss of Eligibility Under Medicaid or a State Children's Health through the Office for Civil Rights Complaint Portal,available at Insurance Program. If you decline enrollment for yourself or for an https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,or by mail or phone eligible dependent(including your spouse)while Medicaid coverage or at: coverage under a state children's health insurance program is in effect, Department of Health and Human Services you may be able to enroll yourself and your dependents in this plan if 200 Independence Avenue,SW Room 509F,HHH Building you or your dependents lose eligibility for that other coverage. Washington,D.C.20201 However, you must request enrollment within 60 days after your or 1-800-368-1019,800-537-7697(TDD) your dependents'coverage ends under Medicaid or a state children's Complaint forms are available at http://www.hhs.gov/oc r/office/ health insurance program. file/index.html. New Dependent by Marriage, Birth, Adoption, or Placement for Adoption.If you have a new dependent as a result of marriage,birth, Social Security Numbers Generally Required for adoption,or placement for adoption,you may be able to enroll yourself Enrollment and your new dependents. However, you must request enrollment Under Section 111 of the Medicare,Medicaid,and SCHIP Extension within 31 days after the marriage, birth, adoption, or placement for Act of 2007 (MMSEA), the Centers for Medicare and Medicaid adoption. Services (CMS) generally requires Social Security numbers for Eligibility for Medicaid or a State Children's Health Insurance Program. employees and dependents to assist with reporting under the If you or your dependents(including your spouse)become eligible for a Medicare Secondary Payer requirements. Accordingly, School state premium assistance subsidy from Medicaid or through a state District of Indian River will require that you provide Social Security children's health insurance program with respect to coverage under this numbers at the time of enrollment,so that School District of Indian plan,you may be able to enroll yourself and your dependents in this River County can assist its health plan administrator(s) to comply plan.However,you must request enrollment within 60 days after your with this requirement. or your dependents'determination of eligibility for such assistance. For a newborn or newly adopted child, the newborn may be All enrollment changes due to special enrollment rights are subject to enrolled, provided that School District of Indian River County is the approval of the Plan Administrator. notified within 30 days of the birth, adoption, or placement for adoption. However, if a Social Security number is not provided by Discrimination is Against the Law the later of(1)the end of the plan year,or(2)90 days following the School District of Indian River County complies with applicable Federal birth, adoption, or placement for adoption, the child will be civil rights laws and does not discriminate on the basis of race,color, disenrolled from the plan and will no longer be considered eligible national origin, age, disability, or sex. School District of Indian River for coverage.The child cannot be re-enrolled until the Social Security County does not exclude people or treat them differently because of number is provided, and the child meets one of the mid-year race,color,national origin,age,disability,or sex. enrollment or change in status coverage events. School District of Indian River County Provides free aids and services to people with disabilities to COBRA communicate effectively with us,such as: If you,your spouse,or eligible dependent loses coverage under any Qualified sign language interpreters School District of Indian River County group medical or dental plan • Written information in other formats(large print,audio,accessible because of a COBRA-qualifying event, you may have the right to electronic forthats,other formats) continue coverage under the Consolidated Omnibus Budget • Provides free language services to people whose primary language Reconciliation Act(COBRA).For details about qualifying events,refer is not English,such as: to the Initial COBRA Notice. • Qualified interpreters If your coverage ends due to a COBRA-qualifying event, you will • Information written in other languages receive a notice of your continuation rights.At that time,you will If you need these services,contact Equity&Compliance Officer.If you have up to 60 days—from the date of your event or the date you believe that School District of Indian River County has failed to provide received your notice—to decide whether you want to continue your these services or discriminated in another way on the basis of race, health coverage. color, national origin, age, disability, or sex, you can file a grievance If you, your spouse, and/or dependent have a COBRA qualifying with: 69 34