Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 4431 Legislative Information CHIP (continued) If you live in one of the following states, you may be eligible for assistance paying your employer health plan premi- ums. The following list of states is current as of July 31, 2015. Contact your State for more information on eligibility – To see if any other states have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 CHILDREN’S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA) SPECIAL ENROLLMENT RIGHTS Effective April 1, 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) creates two new special enrollment rights for employees and their dependents. All group health plans must permit eligible employees and their dependent(s) to enroll in an employer plan if the employee requests enrollment under the group health plan within 60 days of the occurrence of following events: 1.  Loss of coverage under Medicaid or a state child health plan. 2.  Gaining eligibility for coverage under Medicaid or a state child health plan: The Eligible Person previously declined coverage under the Plan. 3.  Event Takes Place (for example, a birth, marriage or determination of eligibility for state subsidy). 4.  Missed Initial Enrollment Period or Open Enrollment Period. Please note: Once you terminate your enrollment in our group health plan, your children’s enrollment will also be terminated. Failure to notify us of your loss or gain of eligibility for coverage under Medicaid or a state children’s health plan within 60 days, will prevent you from enrolling in our plans and/or making any changes to your coverage elections until our next open enrollment period. To request special enrollment or if you have questions regarding these disclosures please contact the Benefits Team at You may also find more information by visiting NORTH CAROLINA – Medicaid PENNSYLVANIA – Medicaid WEST VIRGINIA – Medicaid 1-919-855-4100 1-800-692-7462 1-877-598-5820, HMS 3rd Party Liability GEORGIA – Medicaid VIRGINIA – Medicaid and CHIP Medicaid Website & Phone: Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) 1-800-432-5924 1-800-869-1150 CHIP Website & Phone: 1-855-242-8282