2023 Compliance Notices
Women’s Health and Cancer Rights
If 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. Therefore, the following deductibles and coinsurance apply:
- Red Plan: $500 Individual / $1,000 Family deductible; 20% coinsurance
- Blue Plan: $600 Individual / $1,200 Family deductible; 20% coinsurance
- White Plan: $1,200 Individual / $2,400 Family deductible; 30% coinsurance
- Green Plan: $2,500 Individual / $5,000 Family deductible; 20% coinsurance
Notice of Availability of Notice of Privacy Practices
This notice describes how you may obtain a copy of the Plan’s Notice of Privacy Practices, which describes the ways that the Plan uses and discloses your protected health information.
The Nemours Group Health Plan (the “Plan”) provides health benefits to eligible employees of Nemours Children’s Health (the “Company”) and their eligible dependents as described in the summary plan description(s) for the Plan. The Plan creates, receives, uses, maintains and discloses health information about participating employees and dependents in the course of providing these health benefits. The Plan is required by law to provide notice to participants of the Plan’s duties and privacy practices with respect to covered individuals’ protected health information and has done so by providing to Plan participants a Notice of Privacy Practices, which describes the ways that the Plan uses and discloses protected health information. To receive a copy of the Plan’s Notice of Privacy Practices, please contact Catherine Reed, who has been designated as the Plan’s contact person for all issues regarding the Plan’s privacy practices and covered individuals’ privacy rights. You can reach Catherine in writing at 10140 Centurion Parkway North, Jacksonville, FL 32256; by phone at 904.697.5656 or via email at firstname.lastname@example.org.
Imputed Income Reminder
Employers are required by the IRS to apply imputed income when calculating income taxes for any employer-provided life insurance in excess of $50,000, as the value of these benefits is taxable to the employee. For more information, email email@example.com.
Medicare Part D Annual Notice
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Nemours 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:
- 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.
- Nemours Children’s has determined that the prescription drug coverage offered by the Nemours 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 15 through December 7. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two-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 Nemours coverage will not be affected. Your Nemours plan will be primary and Medicare secondary.
If you do decide to join a Medicare drug plan and drop your current Nemours coverage, be aware that you and your dependents will not be able to get this coverage back until the following annual enrollment.
When 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 coverage with Nemours, 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 percent of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without Creditable Coverage, your premium may consistently be at least 19 percent 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
Contact the person listed below for further information. 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 Nemours 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 (800) MEDICARE or 800.633.4227, TTY users should call 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 800.772.1213, TTY users should call 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: October 2022
Name of Entity/Sender: Nemours Children’s Health
Contact – Position/Office: Catherine Reed, Benefits Manager
Address: 10140 Centurion Parkway North, Jacksonville, FL 32256
Phone Number: 904.697.5656
Summary Annual Report for Nemours Foundation Employee Welfare Benefit Plan
This is a summary of the annual report of the Nemours Foundation Employee Welfare Benefit Plan, a health, life insurance, dental, vision, temporary disability, prepaid legal, long-term disability and Employee Assistance Program plan (Employer Identification Number (EIN) 59-0634433, Plan Number 513) for the plan year Jan. 1, 2021, through Dec. 31, 2021. The annual report has been filed with the Employee Benefits Security Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA).
The Nemours Foundation has committed itself to pay certain medical, prescription, dental and short-term disability claims incurred under the terms of the plan.
The plan has insurance contracts with MetLife Legal Plans, Reliance Matrix Life Insurance Company, Metropolitan Life Insurance Company, Unum Life Insurance Company of America, Vision Service Plan, Life Insurance Company of North America, Health, Human Resource Center and Aetna Behavioral Health to pay certain legal, life insurance, accidental death and dismemberment (AD&D), critical illness, accident, hospital indemnity, long-term care, vision, long-term disability claims and Employee Assistance Program services incurred under the terms of the plan. The total premiums paid for the plan year ending Dec. 31, 2022, were $5,721,304.
Your Rights to Additional Information
You have the right to receive a copy of the full annual report, or any part thereof, on request. The item listed below is included in that report:
- Insurance information, including sales commissions paid by insurance carriers.
To obtain a copy of the full annual report, or any part thereof, write or call the office of Rodney McKendree, who is a representative of the plan administrator, at 10140 Centurion Parkway North, Jacksonville, FL 32256 and phone number, 904.697.5648. You also have the legally protected right to examine the annual report at the main office of the plan at 10140 Centurion Parkway North, Jacksonville, FL 32256, and at the U.S. Department of Labor in Washington, D.C., or to obtain a copy from the U.S. Department of Labor upon payment of copying costs.
Requests to the Department should be addressed to:
Public Disclosure Room, Room N-1513
Employee Benefits Security Administration
U.S. Department of Labor
200 Constitution Avenue, N.W.
Washington, D.C. 20210
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 firstname.lastname@example.org and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023)
Nemours complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
Language services are available at no cost. If you need assistance, please contact Nemours Benefits and we will provide you with an interpreter.
Premium 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 additional information please view CHIP notice.
Health Contingent Reasonable Alternative Standard (RAS) Notice Tobacco User Surcharge
Stop smoking today! We can help! If you are a smoker, we offer a smoking cessation program. We will work with you and your doctor to help you stop smoking. If you complete the program, you can avoid this surcharge. Please contact us at 877.931.8005 to get started.
HIPAA Special Enrollment Notice
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 or 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 60 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as 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 60 days after the marriage, birth, adoption, or placement for adoption.
Special enrollment rights also may exist in the following circumstances:
- If you or your dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP) coverage and you request enrollment within 60 days after that coverage ends; or
- If you or your dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with respect to coverage under this plan and you request enrollment within 60 days after the determination of eligibility for such assistance.
Note: The 60-day period for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state CHIP. As described above, a 60-day period applies to most special enrollments.
As stated earlier in this notice, a special enrollment opportunity may be available in the future if you or your dependents lose other coverage. This special enrollment opportunity will not be available when other coverage ends, however, unless you provide a written statement explaining the reason that you are declining coverage for yourself or your dependent(s). Failing to accurately complete and return this form for each person for whom you are declining coverage may eliminate this special enrollment opportunity for the person(s) for whom a statement is not completed, even if other coverage is currently in effect and is later lost. In addition, unless you indicate in the statement that you are declining coverage because other coverage is in effect, you may not have this special enrollment opportunity for the person(s) covered by the statement. (See the paragraphs above, however, regarding enrollment in the event of marriage, birth, adoption, placement for adoption, loss of eligibility for Medicaid or a state CHIP, and gaining eligibility for a state premium assistance subsidy through Medicaid or a state CHIP.)
Surprise Billing Notice
Your Rights and Protections Against Surprise Medical Bills
Effective Jan. 1, 2023
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected by federal law from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care — like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as deductibles, copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Department of Labor or your medical vendor. Visit the Department of Labor’s website (www.dol.gov/ebsa)or call the Employee Benefits Security Administration (EBSA) Toll-Free Hotline at 1.866.444.EBSA (3272) for more information about your rights under federal law.
Contact your medical vendor by calling the Aetna member services number at 855.878.4195.
The contents of this notice do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This information is intended only to provide clarity to the public regarding existing requirements under the law.