Patient Protection Disclosure (for HMO IL Medical Plan Enrollees Only)

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Patient Protection Disclosure (for HMO IL Medical Plan Enrollees Only)The HMO Illinois medical plan requires the designation of a primary care provider. You have the rightto designate any primary care provider who participates in our network and who is available to acceptyou or your family members. For information on how to select a primary care provider, and for a list ofthe participating primary care providers, contact BlueCross BlueShield at (800) 892-2803. For children,you may designate a pediatrician as the primary care provider.You do not need prior authorization from BlueCross BlueShield or from any other person (including aprimary care provider) in order to obtain access to obstetrical or gynecological care from a health careprofessional 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 authorizationfor certain services, following a pre-approved treatment plan, or procedures for making referrals. For alist of participating health care professionals who specialize in obstetrics or gynecology, contact theBCBS at (800) 892-2803.

Premium Assistance Under Medicaid and theChildren’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 orCHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premiumassistance 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 yourState 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 dependentsmight be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW orwww.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help youpay 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 youremployer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This iscalled a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligiblefor premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Laborat www.askebsa.dol.gov or call 1-866-444-EBSA (3272).If you live in one of the following states, you may be eligible for assistance paying your employer health planpremiums. The following list of states is current as of January 31, 2017. Contact your State for more informationon eligibility –ALABAMA – MedicaidWebsite: http://myalhipp.com/Phone: 1-855-692-5447ALASKA – MedicaidThe AK Health Insurance Premium Payment ProgramWebsite: http://myakhipp.com/Phone: 1-866-251-4861Email: CustomerService@MyAKHIPP.comMedicaid aid/default.aspxARKANSAS – MedicaidWebsite: http://myarhipp.com/Phone: 1-855-MyARHIPP (855-692-7447)COLORADO – Health First Colorado(Colorado’s Medicaid Program) &Child Health Plan Plus (CHP )Health First Colorado Website:https://www.healthfirstcolorado.com/Health First Colorado Member Contact Center:1-800-221-3943/ State Relay 711CHP : Colorado.gov/HCPF/Child-Health-Plan-PlusCHP Customer Service: 1-800-359-1991/State Relay 711FLORIDA – MedicaidWebsite: http://flmedicaidtplrecovery.com/hipp/Phone: 1-877-357-3268GEORGIA – MedicaidWebsite: http://dch.georgia.gov/medicaid- Click on Health Insurance Premium Payment (HIPP)Phone: 404-656-4507INDIANA – MedicaidHealthy Indiana Plan for low-income adults 19-64Website: http://www.in.gov/fssa/hip/Phone: 1-877-438-4479All other MedicaidWebsite: http://www.indianamedicaid.comPhone 1-800-403-0864IOWA – dicaid-a-to-z/hippPhone: 1-888-346-9562

KANSAS – MedicaidWebsite: http://www.kdheks.gov/hcf/Phone: 1-785-296-3512KENTUCKY – MedicaidWebsite: http://chfs.ky.gov/dms/default.htmPhone: 1-800-635-2570LOUISIANA – /subhome/1/n/331Phone: 1-888-695-2447MAINE – MedicaidWebsite: ex.htmlPhone: 1-800-442-6003TTY: Maine relay 711MASSACHUSETTS – Medicaid and nts/masshealth/Phone: 1-800-462-1120MINNESOTA – MedicaidWebsite: calassistance.jspPhone: 1-800-657-3739MISSOURI – ants/pages/hipp.htmPhone: 573-751-2005MONTANA – arePrograms/HIPPPhone: 1-800-694-3084NEBRASKA – MedicaidWebsite:http://dhhs.ne.gov/Children Family Services/AccessNebraska/Pages/accessnebraska index.aspxPhone: 1-855-632-7633NEVADA – MedicaidMedicaid Website: https://dwss.nv.gov/Medicaid Phone: 1-800-992-0900NEW HAMPSHIRE – ts/hippapp.pdfPhone: 603-271-5218NEW JERSEY – Medicaid and CHIPMedicaid /clients/medicaid/Medicaid Phone: 609-631-2392CHIP Website: http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710NEW YORK – MedicaidWebsite: https://www.health.ny.gov/health care/medicaid/Phone: 1-800-541-2831NORTH CAROLINA – MedicaidWebsite: https://dma.ncdhhs.gov/Phone: 919-855-4100NORTH DAKOTA – icalserv/medicaid/Phone: 1-844-854-4825OKLAHOMA – Medicaid and CHIPWebsite: http://www.insureoklahoma.orgPhone: 1-888-365-3742OREGON – MedicaidWebsite: //www.oregonhealthcare.gov/index-es.htmlPhone: 1-800-699-9075PENNSYLVANIA – ogram/index.htmPhone: 1-800-692-7462RHODE ISLAND – MedicaidWebsite: http://www.eohhs.ri.gov/Phone: 401-462-5300SOUTH CAROLINA – MedicaidWebsite: https://www.scdhhs.govPhone: 1-888-549-0820

SOUTH DAKOTA - MedicaidWASHINGTON – MedicaidWebsite: http://dss.sd.govPhone: 1-888-828-0059Website: e: 1-800-562-3022 ext. 15473TEXAS – MedicaidWEST VIRGINIA – MedicaidWebsite: http://gethipptexas.com/Phone: edicaid%20Expansion/Pages/default.aspxPhone: 1-877-598-5820, HMS Third Party LiabilityUTAH – Medicaid and CHIPWISCONSIN – Medicaid and CHIPMedicaid Website: https://medicaid.utah.gov/CHIP Website: http://health.utah.gov/chipPhone: v/publications/p1/p10095.pdfPhone: 1-800-362-3002VERMONT– MedicaidWYOMING – MedicaidWebsite: http://www.greenmountaincare.org/Phone: 1-800-250-8427Website: https://wyequalitycare.acs-inc.com/Phone: 307-777-7531VIRGINIA – Medicaid and CHIPMedicaid Website:http://www.coverva.org/programs premium assistance.cfmMedicaid Phone: 1-800-432-5924CHIP Website:http://www.coverva.org/programs premium assistance.cfmCHIP Phone: 1-855-242-8282To see if any other states have added a premium assistance program since January 31, 2017, or for more information onspecial enrollment rights, contact either:U.S. Department of LaborEmployee Benefits Security BSA (3272)U.S. Department of Health and Human ServicesCenters for Medicare & Medicaid Serviceswww.cms.hhs.gov1-877-267-2323, Menu Option 4, Ext. 61565Paperwork Reduction Act StatementAccording to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection ofinformation unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notesthat a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, anddisplays a currently valid OMB control number, and the public is not required to respond to a collection of information unless itdisplays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no personshall be subject to penalty for failing to comply with a collection of information if the collection of information does not display acurrently 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, Officeof Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 oremail ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.OMB Control Number 1210-0137 (expires 12/31/2019)

Privacy Notice ReminderNorthwestern UniversityThe privacy rules under the Health Insurance Portability and Accountability Act (HIPAA) requirethe Northwestern University health plan (the “Plan”) to periodically send a reminder to participantsabout the availability of the Plan’s Privacy Notice and how to obtain that notice. The PrivacyNotice explains participants’ rights and the Plan’s legal duties with respect to protected healthinformation (PHI) and how the Plan may use and disclose PHI.To obtain a copy of the Privacy Notice contact the Health & Welfare/Absence Manager at 847467-0673. You may also view the Privacy Notice online s/index.html.You may also contact the Plan’s Privacy Official at 847-491-8588 for more information on thePlan’s privacy policies or your rights under HIPAA.WRG only: #20066227

HIPAA Special Enrollment NoticeIf you are declining enrollment for yourself or your dependents (includingyour spouse) because of other health insurance or group health plancoverage, you may be able to enroll yourself and your dependents in thisplan if you or your dependents lose eligibility for that other coverage(or if the employer stops contributing toward your or your dependents’other coverage). However, you must request enrollment within 31 daysafter your or your dependents’ other coverage ends (or after the employerstops contributing toward the other 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 yourselfand your dependents. However, you must request enrollment within 31days after the marriage, birth, adoption, or placement for adoption.To request special enrollment or obtain more information, contact theBenefits Division at 847-491-7513.* Source: US Department of Labor, Employee Benefits Security Administration. Compliance Assistance Guide:Health Benefits Coverage Under Federal Law, Washington, DC: October 2010, p. 102, available athttp://www.dol.gov/ebsa/pdf/CAG.pdf. Language used in the model appears in the final HIPAA portabilityregulations at 29 CFR § 2590.701–6(c)(1).

Important Notice from Northwestern University AboutYour Prescription Drug Coverage and MedicarePlease read this notice carefully and keep it where you can find it. This notice hasinformation about the current prescription drug coverage available throughNorthwestern University and about your options under Medicare’s prescription drugcoverage. This information can help you decide whether or not you want to join aMedicare drug plan. If you are considering joining, you should compare your currentcoverage, including which drugs are covered at what cost, with the coverage andcosts of the plans offering Medicare prescription drug coverage in your area.Information about where you can get help to make decisions about your prescriptiondrug coverage is at the end of this notice.There are two important things you need to know about your current coverage andMedicare’s prescription drug coverage:1. Medicare prescription drug coverage became available in 2006 to everyone withMedicare. You can get this coverage if you join a Medicare Prescription Drug Planor join a Medicare Advantage Plan (like an HMO or PPO) that offers prescriptiondrug coverage. All Medicare drug plans provide at least a standard level ofcoverage set by Medicare. Some plans may also offer more coverage for a highermonthly premium.2. Northwestern University has determined that the prescription drug coverageoffered by our health plans is, on average for all plan participants, expected to payout as much as standard Medicare prescription drug coverage pays and istherefore considered Creditable Coverage. Because your existing coverage isCreditable Coverage, you can keep this coverage and not pay a higher premium (apenalty) 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 eachyear from October 15th through December 7th.However, if you lose your current creditable prescription drug coverage, through no fault ofyour own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to joina Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join AMedicare Drug Plan?If you decide to join a Medicare drug plan, your current Northwestern University coverage willnot be affected.Your Northwestern University coverage pays for other medical expenses in addition toprescription drugs. If you or your covered family member enrolls in a Medicare drug plan,your Northwestern University medical and prescription drug coverage will coordinate withMedicare and as a result, generally will not be impacted. For example, for active employeesand spouses of active employees, Northwestern University’s group health plan will paybenefits first. Then, Medicare will coordinate with the Northwestern University group healthplan. However, you should be aware that Northwestern University will not reimburse you forany Part D premium that may apply to your enrollment in a Medicare drug plan.If you do decide to join a Medicare drug plan as a retiree and drop your current NorthwesternUniversity retiree coverage, be aware that you and your dependents will not be able to getthis coverage back.When Will You Pay A Higher Premium (Penalty) To Join A Medicare DrugPlan?You should also know that if you drop or lose your current coverage with NorthwesternUniversity and don’t join a Medicare drug plan within 63 continuous days after your currentcoverage 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, yourmonthly premium may go up by at least 1% of the Medicare base beneficiary premium permonth for every month that you did not have that coverage. For example, if you go nineteenmonths without creditable coverage, your premium may consistently be at least 19% higherthan the Medicare base beneficiary premium. You may have to pay this higher premium (apenalty) as long as you have Medicare prescription drug coverage. In addition, you may haveto wait until the following November to join.For More Information About This Notice Or Your Current PrescriptionDrug Coverage Contact the person listed below for further information. NOTE: You’ll get this notice eachyear. You will also get it before the next period you can join a Medicare drug plan, and if thiscoverage through Northwestern University changes. You also may request a copy of thisnotice at any time.

For More Information About Your Options Under Medicare PrescriptionDrug 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 fromMedicare. 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 ofyour copy of the “Medicare & You” handbook for their telephone number) forpersonalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.If you have limited income and resources, extra help paying for Medicare prescription drugcoverage is available. For information about this extra help, visit Social Security on the web atwww.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).Remember: Keep this Creditable Coverage notice. If you decide to joinone of the Medicare drug plans, you may be required to provide a copy ofthis notice when you join to show whether or not you have maintainedcreditable coverage and, therefore, whether or not you are required to paya higher premium (a penalty).Date:Name of Entity/Sender:Contact--Position/Office:Phone Number:10/01/2020Northwestern UniversityRetirement Plans ManagerAddress: 720 University PlaceEvanston, IL 60208847-491-7513

WHCRA Annual NoticeDo you know that your plan, as required by the Women’s Health and CancerRights Act of 1998, provides benefits for mastectomy-related services includingall stages of reconstruction and surgery to achieve symmetry between thebreasts, prostheses, and complications resulting from a mastectomy, includinglymphedema? Call your plan administrator at 847-491-7513 for moreinformation.* Source: US Department of Labor, Employee Benefits Security Administration. Compliance Assistance Guide:Health Benefits Coverage Under Federal Law, Washington, DC: October 2010, p. 110, available athttp://www.dol.gov/ebsa/pdf/CAG.pdf.

NMHPA DisclosureGroup health plans and health insurance issuers generally may not, underFederal law, restrict benefits for any hospital length of stay in connectionwith childbirth for the mother or newborn child to less than 48 hoursfollowing a vaginal delivery, or less than 96 hours following a cesareansection. However, Federal law generally does not prohibit the mother’s ornewborn’s attending provider, after consulting with the mother, fromdischarging the mother or her newborn earlier than 48 hours (or 96 hoursas applicable). In any case, plans and issuers may not, under Federal law,require that a provider obtain authorization from the plan or theinsurance issuer for prescribing a length of stay not in excess of 48 hours(or 96 hours).* Source: US Department of Labor, Employee Benefits Security Administration. Compliance Assistance Guide:Health Benefits Coverage Under Federal Law, Washington, DC: October 2010, p. 108, available athttp://www.dol.gov/ebsa/pdf/CAG.pdf. Language used in the model appears in the final HIPAA portabilityregulations at 29 CFR § 2520.102–3(t)(2).

1. 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.

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