Important AlaskaCare Benefit Program Notices

Updated October 2016

This newsletter contains important AlaskaCare benefit program notices of interest to you and your family. Please share this information with your family members. Some of the notices in this newsletter are required by law and other notices contain helpful information. These notices are updated from time to time and some of the federal notices are updated each year. Be sure you are reviewing the most updated version of these important notices.

Cobra Coverage Reminder

In compliance with a federal law referred to as COBRA Continuation Coverage, this plan offers AlaskaCare members and their covered dependents (known as qualified beneficiaries) the opportunity to elect temporary continuation of their group health coverage when that coverage would otherwise end because of certain events (called qualifying events).

Qualified beneficiaries are entitled to elect COBRA when qualifying events occur, and, as a result of the qualifying event, coverage of that qualified beneficiary ends. Qualified beneficiaries who elect COBRA Continuation Coverage must pay for it at their own expense. Current defined benefit retirees COBRA rates are available here and current active COBRA rates are available here.

Qualifying events include termination of employment, reduction in hours of work making the employee ineligible for coverage, death of the employee, divorce/legal separation, or a child ceasing to be an eligible dependent child.

In addition to considering COBRA as a way to continue coverage, there may be other coverage options for you and your family. You may want to look for coverage through the Health Care Marketplace at healthcare.gov. In the Marketplace, you could be eligible for a tax credit that lowers your monthly premiums for Marketplace coverage, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan) if you request enrollment within 30 days, even if the plan generally does not accept late enrollees.

The maximum period of COBRA coverage is generally either 18 months or 36 months, depending on which qualifying event occurred.

In order to have the chance to elect COBRA coverage after a divorce/legal separation or a child ceasing to be a dependent child under the plan, you and/or a family member must inform the plan in writing of that event no later than 60 days after that event occurs. That notice should be sent to:

Division of Retirement and Benefits
P.O. Box 110203
Juneau, AK 99811-0203

The notice should be sent via first class mail and is to include the AlaskaCare member’s name, the qualifying event, the date of the event, and the appropriate documentation in support of the qualifying event (such as divorce documents).

If you have questions about COBRA, contact the concierge at (855) 784-8646. For a complete list of qualifying events and for additional information on your COBRA rights refer to the COBRA section of the AlaskaCare Employee Health Plan document, pages 97-101 of the AlaskaCare Retiree Insurance Information Booklet, or to the COBRA section of the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees.

Important Notice from AlaskaCare About Your Prescription Drug Coverage and Medicare

If you and/or your family members are not now eligible for Medicare and will not be eligible for Medicare during the next 12 months, you may disregard this notice. If, however, you and/or your family members are now eligible for Medicare or may become eligible for Medicare in the next 12 months, please read this notice very carefully and keep it where you can find it. This notice has information about your AlaskaCare prescription drug coverage 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 AlaskaCare 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:

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. Some plans may also offer more coverage for a higher monthly premium.
2. The State of Alaska has determined that the prescription drug coverage offered by the AlaskaCare Defined Benefit Retiree Health Plans and AlaskaCare Retiree Benefit Plan for DCR Plan Retirees is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is 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 to 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 (2) 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 AlaskaCare coverage will be affected as follows. If you are a participant in the defined benefit retiree health plan or the retiree benefit plan for DCR plan retirees and purchase Medicare prescription drug coverage, your AlaskaCare plan will become supplemental to Medicare’s drug plan. Conversely, if you are a participant in the employee health plan and purchase Medicare prescription drug coverage, Medicare will become the secondary prescription drug plan.

If you are a participant in the defined benefit retiree health plan or the retiree benefit plan for DCR plan retirees and decide to join a Medicare drug plan and drop your current AlaskaCare coverage, be aware that you and your dependents will not be able to get this coverage back.

Benefits Provided by Your AlaskaCare Prescription Drug Plan (Employee Plan [Effective 1/1/17] and Retiree Benefit Plan for DCR Plan Retirees)

Prescription Teir	Coinsurance	Min. Covered Person Payment	Max. Covered Person Payment
Retail 30-Day at Network Pharmacy
Generic prescription drug	80%	$10	$50
Preferred brand-name prescription drug	75%	$25	$75
Non-preferred brand-name prescription drug	65%	$80	$150
Mail Order 31-90 Day at Network Pharmacy
Prescription Teir		Copayment
Generic prescription drug		$20
Preferred brand-name prescription drug		$50
Non-preferred brand-name prescription drug		$100
Out-of-Pocket Limit
Annual individual out-of-pocket limit		$1,000
Annual family out-of-pocket limit		$2,000

Benefits Provided by Your AlaskaCare Prescription Drug Plan (Defined Benefit Retiree Plan)

		Up to 90-Day or 100-Unity Supply
Brand-name		$8
Generic		$4
Brand-name mail order		$0
Generic mail order		$0

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 AlaskaCare coverage 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% 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% 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 AlaskaCare Prescription Drug Coverage

Contact the Alaska Medicare Information Office at (800) 478-6065 (in Anchorage (907) 269-3680) or the Aetna concierge at (855) 784-8646.

NOTE: You’ll receive this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if there are any changes to your AlaskaCare prescription drug coverage. 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 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 (1-800 -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 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 2016
Name of Sender: State of Alaska, Division of Retirement and Benefits
Contact: Member Services Contact Center
Address: PO Box 110203, Juneau, AK 99811-0203
Telephone: (907) 465-4460
Toll Free: (800) 821-2251

Availability of Summary of Benefit and Coverage (SBC) Document(s)

The health benefits available to you from the State of Alaska AlaskaCare Employee Health Plan represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. In accordance with law, our employee plan provides you with Summary of Benefits and Coverage, or SBC, documents as a way to help you understand and compare medical plan benefits. Each SBC summarizes and compares important information including what is covered, what you need to pay for various benefits, what is not covered, and where to get answers to questions. SBC documents are updated when there is a change to the benefits information displayed on an SBC. To get a free copy of the most current SBC documents for our State of Alaska medical plan options, go to AlaskaCare.gov, or for a paper copy, contact the Division of Retirement and Benefits toll free at (800) 821-2251 or (907) 465-4460 in Juneau.

Notice of Privacy Practices—AlaskaCare Health Plans

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE OF PRIVACY PRACTICE PERTAINS TO...

Your Individual Privacy Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

You have the right to:

Get a copy of your health and claims records

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations.
• We are not required to agree to your request, and we may say “no” if the Privacy Officer determines it to be unreasonable.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints.
• We will not retaliate against you for filing a complaint.

Notify you of a breach

• If a breach of your unsecured health information occurs, we will notify you.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in payment for your care.
• Contact you for fundraising efforts.
• Share information in a disaster relief situation. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information

Uses and Disclosures Without Authorization

We may use of share your health information without your written permission in certain circumstances:

Help manage the health care treatment you receive

• We can use your health information and share it with professionals who are treating you.

Example: We disclose to a treating specialist the name of your treating primary care physician so the two can confer regarding your treatment plan.

Run our organization

• We can use and disclose your information to run our organization and contact you when necessary.
• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Pay for your health services

• We can use and disclose your health information as we pay for your health services.

Example: We tell your doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.

Administer your plan

• We may disclose your health information to your health plan sponsor for plan administration.

Example: We review information about your medical claims to refer you to a health care management program.

How else can we use or share your health information?

• We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as helping with product recalls or reporting adverse reactions to medications.

For research

• We can use or share your information for health research, subject to certian condtions.

To a school for required proof of immunizations when required by law

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can share health information about you with organ procurement organizations.
• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

To comply with workers’ compensation programs for public health oversight activitis authorized by law

• We can share health information with public health agencies for oversight of benefit programs (for example, to investigate Medicare fraud).

For specialized government functions

• We can share your information for special government functions such as military, national security, and presidential protective services.

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or administrative order, or in response to a subpoena.

For law enforcement purposes

• We can share health information about you to law enforcement officials in urgent circumstances such as for identifying a suspect or victim of a crime.

When Disclosure Requires Your Authorization

Generally, we will require that you sign a valid authorization form in order to use or disclose your health information other than:

• When you request your own PHI
• A government agency requires it, or
• The plan uses it for treatment, payment or health care operation.

You have the right to revoke an authorization.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the legal duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:
hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

This Notice of Privacy Practices applies to the following organizations:

This Notice of Privacy Practices applies to the benefits in the State of Alaska Employee Health Plan, the State of Alaska Retiree Benefit Plan, and the State of Alaska Retiree Benefit Plan for DCR Plan Retirees that pay for the cost of, or provide medical benefits (which may include health, dental, vision, employee assistance, wellness, medical flexible spending accounts, COBRA administration, or other coverage affecting any structure of the body as those benefits may be offered from time to time). It does not apply to other benefits provided by the State of Alaska, such as life insurance, disability benefits, or accidental death and dismemberment insurance. If you receive health benefits through an insurance company through the State of Alaska you may also receive a notice from the insurer. That notice will describe how the insurer will use your health information and provide your rights.

The effective date of this Privacy Notice is January 1, 2019 and this notice replaces notices previously distributed to you.

For questions, contact Steve Ramos, HIPAA Privacy Officer, at (907) 465-4460 or

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 are eligible for health coverage from your employer, the State of Alaska 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 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 healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in the State of Alaska, contact ALASKA – Medicaid at (888) 318-8890 or (907) 269-6529 in Anchorage 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, contact the Alaska Medicaid or CHIP office at (888) 318-8890 or (907) 269-6529 in Anchorage or visit insurekidsnow.gov to find out how to apply. If you qualify, ask Alaska Medicaid if it has a program that might help you pay 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 your employer plan, your employer must allow 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. Please see the AlaskaCare Employee Health Plan document for additional information. If you have questions about enrolling in your employer plan, contact the Division of Retirement and Benefits at , call toll free at (800) 821-2251 or (907) 465-4460 in Juneau.

You may also change your election if you have a change in status or other applicable event. Please see the AlaskaCare Employee Health Plan document for additional information.

To see if any other states have added a premium assistance program since January 31, 2015, or for more information on special enrollment rights, contact either:

U.S. Department of Labor
Employee Benefits Security Administration
Website: dol.gov/ebsa
(866) 444-EBSA (3272)

U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
Website: cms.hhs.gov
(877) 267-2323, Menu Option 4, Ext. 61565

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

Women’s Health and Cancer Rights Act of 1998 (WHCRA) Annual Notice Reminder

If you are covered under the AlaskaCare Employee Health Plan, you or your dependents 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.

Plan limits, deductibles, copayments, and coinsurance apply to these benefits. For more information on WHCRA benefits, see the AlaskaCare Employee Health Plan document or contact the concierge at (855) 784-8646.

Health Reform

Affordable Care Act (commonly called Health Reform) has been changing the country’s health-care system from the moment it was signed into law back in March 2010. In the past six years, we have implemented required Health Reform provisions into our grandfathered Active Employee health plans, such as offering coverage to dependent children up to the age of 26, removing pre-existing condition limitations in the medical plans, removing lifetime and overall annual limits on essential health benefits in the medical plans, assuring that coverage is not rescinded (retrospectively terminated), except for cases of fraud or intentional misrepresentation, medical emergencies in an emergency room to be paid the same in-network or out-of-network, and the ability to request a voluntary external review of a denied claim.

Effective January 1, 2017, we are transitioning our Active Employee medical plans to a Health Reform approved non-grandfathered status, where you will see a variety of additional provisions, such as: added coverage for preventive services, special limits on cost-sharing related to deductibles, copayments and coinsurance, etc. The Active Employee medical plan document and Summary of Benefits and Coverage (SBC) documents, located at AlaskaCare.gov, provide more details about the Health Reform mandated benefits offered by our non-grandfathered medical plans. Questions about your medical plan benefits can be directed to the Aetna Concierge at (855) 784-8646.

Patient Protection Rights of The Affordable Care Act

Designation of a Primary Care Provider (PCP) and Direct Access to OB/GYN Providers:

The active employee medical plans offered by the State of Alaska do not require the selection or designation of a primary care provider (PCP). You have the ability to visit any in-network (or non-network) health care provider; however, payment by the Plan may be less for the use of a non-network provider. To locate an in-network provider for the medical plans, visit AlaskaCare.gov.

You also do not need prior authorization from the Plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology (OB/GYN), contact the Aetna Concierge at (855) 784-8646.

Newborns’ and Mothers’ Health Protection Act Notice

Hospital Length of Stay for Childbirth: Under federal law, group health plans, like the AlaskaCare Employee Health Plan, generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or the newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, the Plan may pay for a shorter stay if the attending Physician (e.g., Physician, or Health Care Practitioner), after consultation with the mother, discharges the mother or newborn earlier.

Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, the AlaskaCare Employee Health Plan may not, under federal law, require that a Physician or other Health Care Practitioner obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification for a length of stay longer than 48 hours for vaginal birth or 96 hours for C-section, contact the concierge at (855) 784-8646 to precertify the extended stay. You may also contact the concierge if you have questions about this Notice. Please review the AlaskaCare Employee Health Plan document for additional information.

Nondiscrimination in Health Care/Elimination of Conflict of Interest

In accordance with the Affordable Care Act, to the extent an item or service is a covered benefit under the Plan, and consistent with reasonable medical management techniques with respect to the frequency, method, treatment or setting for an item or service, the Plan will not discriminate with respect to participation under the Plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. In this context, discrimination means treating a provider differently based solely on the type of the provider’s license or certification. The Plan is not required to contract with any health care provider willing to abide by the terms and conditions for participation established by the Plan. The Plan is permitted to establish varying reimbursement rates based on quality or performance measures.

Additionally, to ensure that the persons involved with adjudicating claims and appeals (such as claim adjudicators and medical experts) act independently and impartially, decisions related to those persons employment status (such as decisions related to hiring, compensation, promotion, termination or retention), will not be made on the basis of whether that person is likely to support a denial of benefits.

General Statement of Nondiscrimination: (Discrimination is Against the Law)

The State of Alaska complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The State of Alaska does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The State of Alaska:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
• Qualified interpreters
• Information written in other languages

If you need these services related to your AlaskaCare health plan, please contact the concierge at (855) 784-8646 or through the Aetna Navigator.

If you believe that the State of Alaska has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, employees can file a grievance with your departments civil rights coordinator. If you need assistance in finding your department’s coordinator, you can contact the State’s Equal Employment Opportunity Program Coordinator, Camille Brill, at (907) 375-7700. Retirees can contact the Division of Retirement and Benefits at (800) 821-2251 or in Juneau at (907) 465-4460.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD). Complaint forms are available at hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak [insert language], language assistance services, free of charge, may be available to you. Contact (855) 784-8646 (TTY: (800) 628-3323).

Language	Message About Language Assistance
Spanish	ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-784-8646 (TTY: 1-800-628-3323).
Chinese	注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-784-8646 (TTY: 1-800-628-3323) 。
Japanese	注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855-784-8646 (TTY:1-800-628-3323)まで、お電話にてご連絡ください。
French	ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-784-8646 (ATS : 1-800-628-3323).
Italian	ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-784-8646 (TTY: 1-800-628-3323).
German	ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-784-8646 (TTY: 1-800-628-3323).
Hmong	LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-855-784-8646 (TTY: 1-800-628-3323).
Vietnamese	CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-784-8646 (TTY: 1-800-628-3323).
Hindi	ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-855-784-8646 (TTY: 1-800-628-3323) पर कॉल करें।
Gujarati	સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-855-784-8646 (TTY: 1-800-628-3323).
Tagalog	PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-784-8646 (TTY: 1-800-628-3323).
Arabic	ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم .(رقم هاتف الصم والبكم: 1-3323-628-800) x855-784-8646-1
Korean	주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-784-8646 (TTY: 1-800-628-3323)번으로 전화해 주십시오.
Thai	เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-855-784-8646 (TTY: 1-800-628-3323).
Russian	ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-784-8646 (телетайп: 1-800-628-3323).
Urdu	خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں 1-855-784-8646  (TTY: 1-800-628-3323).
Cambodian	ប្រយ័ត្ន៖ បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, សេវាជំនួយផ្នែកភាសា ដោយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។ ចូរ ទូរស័ព្ទ 1-855-784-8646 (TTY: 1-800-628-3323)។
Punjabi	ਧਿਆਨ ਦਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਵਿੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-855-784-8646 (TTY: 1-800-628-3323) 'ਤੇ ਕਾਲ ਕਰੋ।
French Creole (Haitian)	ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-784-8646 (TTY: 1-800-628-3323).
Lao	ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-855-784-8646 (TTY: 1-800-628-3323).
Indonesian	PERHATIAN: Jika Anda berbicara dalam Bahasa Indonesia, layanan bantuan bahasa akan tersedia secara gratis. Hubungi 1-855-784-8646 (TTY: 1-800-628-3323).
Hawaiian	E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo [hoʻokomo ʻōlelo], loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1-855-784-8646 (TTY: 1-800-628-3323).

Mid-Year Changes To Your AlaskaCare Employee Health Care Benefit Elections

IMPORTANT: After this open enrollment period is completed, in accordance with IRS regulations, generally you will not be allowed to change your AlaskaCare Employee Health Plan benefit elections or add/delete dependents until next year’s open enrollment unless you have a Special Enrollment Event, other Mid-year Change in Status or Other Applicable Event as outlined in the AlaskaCare Employee Health Plan. For more information, see the AlaskaCare Employee Health Plan document or contact the Division of Retirement and Benefits at 1-800-821-2251 or (907) 465-4460 in Juneau.

HIPAA Special Enrollment Events

If you are an AlaskaCare eligible employee who is a full-time employee, you are required to participate in both the medical plan and the dental plan. The minimum level of coverage is in the economy medical and preventive dental but other options are available. There are situations in which you can change your elections mid-year, including the health flexible spending account (HFSA), consistent with your change in enrollment during the benefit year. If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll your dependents. However, you must request enrollment of the dependent within 30 days after the marriage, birth, adoption, or placement for adoption.

Your eligible dependents may also enroll in the plan if your dependents:

• Have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and you (or your dependents) lose eligibility for that coverage. However, you must request enrollment within 60 days after the Medicaid or CHIP coverage ends.
• Become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment within 60 days after you (or your dependents) are determined to be eligible for such assistance.

To request special enrollment or obtain more information on permissible mid-year changes, see the AlaskaCare Employee Health Plan document or contact the Division of Retirement and Benefits toll free at (800) 821-2251 or (907) 465-4460 in Juneau.

If You Have a Dependent Covered Under the AlaskaCare Health Plans…

Don’t Forget to Provide the Plan with the Taxpayer Identification Number or Social Security Number of Each Dependent Enrolled in a Health Plan

Health Plans are required by law to collect the taxpayer identification number (TIN) or Social Security number (SSN) of each medical plan participant and provide that number on reports that will be provided to the IRS each year. Health Plans are required to make at least two consecutive attempts to gather missing TINs/SSNs.

If a dependent does not yet have a Social Security number, you can go to this website to complete a form to request a SSN: socialsecurity.gov/online/ss-5.pdf. Applying for a Social Security number is FREE.

If you have not yet provided the Social Security number (or other TIN) for each of your dependents that you have enrolled in the health plan(s), please contact the Division of Retirement and Benefits at , call toll free at (800) 821-2251 or (907) 465-4460 in Juneau.