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Important Legal Notices
<br /> Your Group Benefits Under Section 125 Significant cost changes.If the cost you are charged for a coverage option
<br /> Your employee benefit program is a Premium Conversion Plan ("Plan") significantly increases or decreases during the Plan Year,you may make a
<br /> that is administered under the provisions of Section 125 of the Internal corresponding change to your Plan election. Changes that may be made
<br /> Revenue Code ("Code"). These provisions permit your contributions for include commencing participation in the Plan for an option with a decrease
<br /> various employee benefit plans to be deducted from your gross pay before in cost,or,in the case of an increase in cost,revoking an election for that
<br /> calculation of withholding taxes.The result is that you have fewer taxes coverage and, in lieu thereof, either receiving on a prospective basis
<br /> deducted from your paycheck,which increases your take home pay. coverage under a Plan option providing similar coverage or dropping
<br /> Plan elections you make during your initial enrollment and annual coverage if no option providing similar coverage is available.
<br /> enrollment periods are binding for the applicable Plan year.In addition to Significant coverage changes curtailment with or without loss of coverage.
<br /> the HIPAA Special Enrollment Right certain permitted mid-year Plan Significant Curtailment without loss of coverage. If you or your covered
<br /> election changes are permitted. These permitted election changes are Dependent has a curtailment of coverage under the Plan that is significant,
<br /> discussed below. but does not represent a total loss of coverage(for example,there is a
<br /> All enrollment changes due to a permitted election change are subject to significant increase in the deductible,the co-pay,or the out-of-pocket cost
<br /> the approval of the Plan Administrator.The Plan Administrator will have sharing limit),you may revoke your Plan election and elect to receive on a
<br /> the discretionary authority to make a determination as to whether an prospective basis coverage under another Plan option providing similar
<br /> election change has occurred in accordance with the rules and regulations coverage.Coverage under the Plan is significantly curtailed only if there is
<br /> of the Internal Revenue Service an overall reduction in coverage provided under the Plan so as to
<br /> Change in Status constitute reduced coverage generally.Thus,in most cases,the loss of one
<br /> Please see the Notice of HIPAA Special Enrollment Rights for election particular physician in a network does not constitute a significant
<br /> change during the Plan Year if you experience a Change in Status event. curtailment.
<br /> You must notifythe Plan Administrator within 31 days of the event.Any Y Significant curtailment with loss of coverage. If you or your covered
<br /> election change due to a Change in Status event must be on account of Dependent has a curtailment of coverage under the Plan that constitutes a
<br /> and consistent with your Change in Status as determined by the Plan total loss of coverage,you may revoke your Plan election and elect either
<br /> Administrator. to receive on a prospective basis coverage under another Plan option
<br /> Generally, an election change will be considered consistent with your providing similar coverage or to drop coverage if no similar option is
<br /> Change in Status only if it is on account of and corresponds with a Change available.A loss of coverage means a complete loss of coverage under the
<br /> in Status that affects an individual's eligibility for coverage under the Plan Plan option or other coverage option.
<br /> or a plan maintained by the employer of your Dependent. A Change in Addition or improvement of a benefit package option. If the Plan adds a
<br /> Status that affects eligibility under an employer's health plan includes a new coverage option,or if coverage under an existing coverage option is
<br /> Change in Status that results in an increase or decrease in the number of significantly improved during the Plan Year,the Plan may permit eligible
<br /> your Dependents who may benefit from coverage under the Plan. employees(whether or not they have previously made an election under
<br /> Permitted Change in Status events under the Plan include the following: the Plan or have previously elected a coverage option) to revoke their
<br /> • Change in your legal marital status due to marriage, divorce, legal election under the Plan and to make an election on a prospective basis for
<br /> separation,annulment,or death of your spouse,or you enter into a coverage under the new or improved coverage option.
<br /> domestic partnership, dissolve a domestic partnership or your Change in coverage under another employer plan. You may make a
<br /> Domestic Partner dies. prospective election change that is on account of and corresponds with a
<br /> • Change in the number of your Dependents due to birth, death, change made under another employer plan if(i)the other plan permits
<br /> adoption,or placement for adoption. participants to change an election as described in this section,and(ii)the
<br /> • Change in employment status of you, your covered Dependents other plan permits participants to make an election for a period of
<br /> including a termination or commencement of employment, coverage that is other than the Plan Year. For example, if you elect
<br /> commencement of or return from an unpaid leave of absence, a coverage through your spouse's employer's plan and that plan has a
<br /> different annual enrollment period from this Plan, you may make a
<br /> change in worksite, or any other change in employment status, if corresponding election change.
<br /> such change in employment status affects eligibility under a plan. Family and Medical Leave Act. If you take leave under the Family and
<br /> • Change in eligibility status of your Dependent Child(ren)on account Medical Leave Act(FMLA)you may revoke an existing Plan election and
<br /> of age,or any other circumstance affecting eligibility. make another election for the remaining portion of the Plan year as may
<br /> • Change in residence of you or your covered Dependent. be provided for under the FMLA and regulations of the Internal Revenue
<br /> Qualified Medical Child Support Orders.If required by a Qualified Medical Service.
<br /> Child Support Order("QMCSO"),you and/or an eligible dependent will be Exchange Enrollment.Two mid-year election changes will be available to
<br /> enrolled in the Plan in accordance with the terms of the order. Any participants who meet the requirements of these election changes.
<br /> required premiums will be deducted from your compensation. Upon Reduction of Hours. If your hours are reduced to an expected average of
<br /> request to the Plan Administrator,you may obtain,without charge,a copy less than 30 hours per week,you may revoke your election for coverage
<br /> of the Medical Plan's procedures governing QMCSO determinations. under the Plan if you intend to enroll in coverage offered in a government-
<br /> You may make an election change to cancel coverage for your child if a sponsored Exchange(Marketplace) or in another group health plan that
<br /> QMCSO requires your spouse, former spouse, or other individual to offers minimal essential coverage.This election change may be made even
<br /> provide coverage for the child;and that coverage is actually provided. if the reduction in your hours would not cause you to lose coverage under
<br /> Entitlement To or.Loss of Entitlement To Medicare or Medicaid.If you or the Plan. You will be required to provide the Plan Administrator with
<br /> your Covered Dependent becomes entitled to coverage (i.e., becomes evidence that you intend to enroll in another plan with coverage effective
<br /> enrolled) under Part A or Part B of Medicare or Medicaid, other than no later than the first day of the second month following the revocation
<br /> coverage consisting solely of benefits under section 1928 of the Social (i.e.,if your coverage is revoked in May,coverage under the new plan must
<br /> Security Act(the program for distribution of pediatric vaccines),you may begin on July 1).
<br /> make a prospective election change to cancel or reduce coverage under Obtaining Cover Through the Health Insurance Marketplace. If you are
<br /> the Plan for you or your applicable covered Dependent.In addition,if you enrolled in the Plan and are eligible to enroll for coverage in a government-
<br /> or an eligible Dependent has been entitled to coverage under Medicare or sponsored Exchange (Marketplace) during a special or annual open
<br /> Medicaid and loses eligibility for such coverage, you may make a enrollment period, you may prospectively revoke your election for Plan
<br /> prospective election to commence or increase your or your eligible coverage, provided that you certify that you and any related individuals
<br /> Dependent's coverage,as appropriate,under the Plan. whose coverage is being revoked have enrolled or intend to enroll for new
<br /> Significant Change in Cost or Coverage Changes.You may also change your Exchange coverage that is effective beginning no later than the day
<br /> election mid-year due to a significant change in Plan cost or coverage,as immediately following the last day of Plan coverage. 70
<br /> provided below. 35
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