Full Text
IMPORTANT NOTICE FROM DALLAS COUNTY ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Dallas County 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: 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 premium. 2. Dallas County has determined that the prescription drug coverage offered by the Wellmark 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 15th to December 7th. 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 Dallas County coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current Wellmark coverage, be aware that you and your dependents may not be able to get this coverage back. 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 Wellmark 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 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 nineteen 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 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 Acreage 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 “Medicare & You” handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-[PHONE REDACTED]). TTY users should call 1-[PHONE REDACTED]. 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 1-[PHONE REDACTED] (TTY 1- [PHONE REDACTED]). 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: July 1, 2025 Name of Entity/Sender: Dallas County Contact/Office: Beth Deardorff Address: 800 Court Street, Suite 260 Adel, IA 50003 Required Notices 47 ---PAGE BREAK--- Women’s Health Act 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 consultations with the attending physician and the patient, for: • All states of reconstruction of the breast on which the mastectomy was performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses • Treatment of physical complications of the mastectomy, including These benefits will be provided subject to the same deductibles, copays and coinsurance applicable to other medical and surgical benefits provided under your medical plan. For more information on WHCRA benefits, contact your medical plan administrator. Newborns and Mothers’ Health Protection Act For maternity hospital stays, in accordance with federal law, the Plan does not restrict benefits, for any hospital length of stay in connection with childbirth for the mother or newborn child, to less than 48 hours following a vaginal delivery or less than 96 hours following a Cesarean delivery. However, federal law generally does not prevent the mother’s or newborn’s attending care provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). The plan cannot require a provider to prescribe a length of stay any shorter than 48 hours (or 96 hours following a Cesarean delivery). Mental Health Parity Act According to the Mental Health Parity Act of 1996, the lifetime maximum and annual maximum dollar limits for mental health benefits under the medical plan are equal to the lifetime maximum and annual maximum dollar limits for medical and surgical benefits under this plan. However, mental health benefits may be limited to a maximum number of treatment days per year or series per lifetime. Notice of Special Enrollment Rights If you decline enrollment in medical coverage for yourself or your dependents (including your spouse) because of other health insurance coverage, you may be able to enroll yourself or your dependents in Dallas County medical coverage 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 no more than 30 days after your or your dependent’s other coverage ends (or after the employer stops contributing to the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you can enroll yourself and your dependents in Dallas County medical coverage as long as you request enrollment by contacting the benefits manager no more than 30 days after the marriage, birth, adoption or placement for adoption. For more information, contact Beth Deardorff at [PHONE REDACTED]. New Health Insurance Marketplace Coverage Options and Your Health Coverage Beginning in 2014, there is a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your premium right away. Each year, the open enrollment period for health insurance coverage through the Marketplace runs from Nov. 1 through Dec. 15 of the previous year. After Dec. 15, you can get coverage through the Marketplace only if you qualify for a special enrollment period or are applying for Medicaid or the Children’s Health Insurance Program (CHIP). Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.02 percent (as adjusted each year after 2014) of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. (An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.) Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution—as well as your employee contribution to employer-offered coverage— is often excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact Beth Deardorff at [PHONE REDACTED]. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, as well as an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. Required Notices Required Notices 48 ---PAGE BREAK--- Model General Notice of COBRA Continuation Coverage Right Continuation Coverage Rights Under COBRA** Introduction You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay the full cost for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.” When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide notice to: Dallas County Human Resources at 800 Court Street, Suite 260 in Adel, IA. Documentation of the life event will be required. Required Notices Required Notices 49 ---PAGE BREAK--- Model General Notice of COBRA Continuation Coverage Right Continuation Coverage Rights Under COBRA** Introduction (Cont.) How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan, or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Required Notices Required Notices Plan contact information Dallas County Human Resources 800 Court Street, Suite 260, Adel, IA 50003 [EMAIL REDACTED] [PHONE REDACTED] 50 ---PAGE BREAK--- HIPAA Privacy Notice February 16, 2026 Page 1 of 7 HIPAA PRIVACY NOTICE THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW HEALTH PLAN 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 Practices (the "Notice") describes the legal obligations of Dallas County Health Fund Group Insurance Plan (the "Plan") and your legal rights regarding your protected health information held by the Plan under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act). Among other things, this Notice describes how your protected health information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law. We are required to provide this Notice of Privacy Practices to you pursuant to HIPAA. The HIPAA Privacy Rule protects only certain medical information known as "protected health information." Generally, protected health information is health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan, from which it is possible to individually identify you and that relates to: your past, present, or future physical or mental health or condition; the provision of health care to you; or the past, present, or future payment for the provision of health care to you. If you have any questions about this Notice or about our privacy practices, please contact: Dallas County Human Resources Department 800 Court Street, Suite 260 Adel, Iowa 50003 (515) 993-1751 [EMAIL REDACTED] We do not share any of your information for marketing purposes. ---PAGE BREAK--- Your Information. Your Rights. Our Responsibilities. 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. Your Rights You have the right to: • Get a copy of your health and claims records • Correct your health and claims records • Request confidential communication • Ask us to limit the information we share • Get a list of those with whom we’ve shared your information • Get a copy of this privacy notice • Choose someone to act for you • File a complaint if you believe your privacy rights have been violated Your Choices You have some choices in the way that we use and share information as we: • Answer coverage questions from your family and friends • Provide disaster relief • Market our services and sell your information Our Uses and Disclosures We may use and share your information as we: • Help manage the health care treatment you receive • Run our organization • Pay for your health services • Administer your health plan • Help with public health and safety issues • Do research • Comply with the law • Respond to organ and tissue donation requests and work with a medical examiner or funeral director • Address workers’ compensation, law enforcement, and other government requests • Respond to lawsuits and legal actions To the extent that we have your substance use disorder patient records, subject to 42 CFR part 2, we will not share that information for investigations or legal proceedings against you without your written consent or a court order and a subpoena. Your 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. Get a copy of health and claims records ---PAGE BREAK--- • 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, office, or mobile 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,” for example, if it could affect your care. If we agree to your request, we may still share this information in the event that you need emergency treatment. 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 Choose someone to act for you • If someone has authority to act as your personal representative, such as if someone has your 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 complain if you feel we have violated your rights by contacting us using the information on page 1. • 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-[PHONE REDACTED], or visiting • We will not retaliate against you for filing a complaint. ---PAGE BREAK--- 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 • 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 Our Uses and Disclosures How do we typically use or share your health information? We typically use or share your health information in the following ways. Help manage the health care treatment you receive We can use your health information and share it with professionals who are treating you. Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services. 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 share information about you with your dental plan to coordinate payment for your dental work. Administer your plan We may disclose your health information to your health plan sponsor for plan administration. Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge. ---PAGE BREAK--- 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. And in all cases, if we have substance use disorder patient records about you, subject to 42 CFR part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without your consent or a court order and a subpoena. Help with public health and safety issues We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or safety Do research We can use or share your information for health research. Comply with the 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. Address workers’ compensation, law enforcement, and other government requests We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • 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. Our Responsibilities • We are required by law to maintain the privacy and security of your protected health information. • We will let you know if a breach occurs that may have compromised the privacy or security of your information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. ---PAGE BREAK--- • We will not use or share your information other than as described in this notice 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: www.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 provided to you in the manner you have requested per your Consent to Receive Electronic Notices Acknowledgement. ---PAGE BREAK--- HIPAA Privacy Notice February 16, 2026 Page 7 of 7 Complaints If you believe that your privacy rights have been violated, you may file a complaint with the Plan or with the Office for Civil Rights of the United States Department of Health and Human Services. To file a complaint with the Plan, contact All complaints must be submitted in writing. You will not be penalized, or in any other way retaliated against, for filing a complaint with the Office for Civil Rights or with us. Dallas County Human Resources Department 800 Court St., Suite 260 Adel, Iowa 50003 (515) 993-6800 [EMAIL REDACTED] ---PAGE BREAK--- When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible. Your Rights and Protections Against Surprise Medical Bills 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, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service. You’re protected from balance billing for: Emergency services If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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 See a summary of related state balance billing laws at: surprises-act?redirect_source=/publications/maps-and-interactives/2021/feb/state-balance- billing-protections. 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 can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, 62 ---PAGE BREAK--- 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 types of 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 out-of-network care. You can choose a provider or facility in your plan’s network. See a summary of related state balance billing laws at: surprises-act?redirect_source=/publications/maps-and-interactives/2021/feb/state-balance- billing-protections. When balance billing isn’t allowed, you also have these protections: • You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. • Generally, your health plan must: o Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”). o Cover emergency services by out-of-network providers. o 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. o Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit. If you think you’ve been wrongly billed, contact [Insert contact information for entity responsible for enforcing the federal and/or state balance or surprise billing protection laws. The federal phone number for information and complaints is: 1-[PHONE REDACTED]]. Visit for more information about your rights under Visit no-surprises-act?redirect_source=/publications/maps-and-interactives/2021/feb/state-balance- billing-protections for more information about your rights under state laws. 63 ---PAGE BREAK--- HIPAA TRIENNIAL NOTICE Your health insurance coverage with Fidelity Security Life Insurance Company complies with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requirements. These requirements are described in the Notice of Privacy Practices (“Notice”) that was previously provided to you with your insurance policy or certificate. A copy of the Notice is maintained on our Company website at www.fslins.com. If you would like a paper copy of the Notice, please contact your employer. Or, you may contact our Customer Service Department by phone at (800) 648-8624, Monday through Friday 8:30 a.m. to 5:00 p.m., CST, or in writing at: Fidelity Security Life Insurance Company HIPAA Customer Service 3130 Broadway Kansas City, MO 64111-2406 HIPAA TRIENNIAL NOTICE - EMPLOYEE ---PAGE BREAK--- N-00200 93-33087 Rev 0924 FACTS WHAT DOES Fidelity Security Life Insurance Company® and Affiliates DO WITH YOUR PERSONAL INFORMATION? Why? Financial companies choose how they share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. What? The types of personal information we collect and share depend on the product or service you have with us. This information can include: ■ Social Security number and transaction history ■ medical information and insurance claim information ■ assets and checking account information When you are no longer our customer, we continue to share your information as described in this notice. How? All financial companies need to share customers’ personal information to run their everyday business. In the section below, we list the reasons financial companies can share their customers’ personal information; the reasons Fidelity Security Life Insurance Company and Affiliates choose to share; and whether you can limit this sharing. Reasons we can share your personal information Does Fidelity Security Life Insurance Company share? Can you limit this sharing? For our everyday business purposes – such as to process your transactions, maintain your account(s), respond to court orders and legal investigations, or report to credit bureaus Yes No For our marketing purposes – to offer our products and services to you Yes No For joint marketing with other financial companies Yes No For our affiliates’ everyday business purposes – information about your transactions and experiences Yes No For our affiliates’ everyday business purposes – information about your creditworthiness No We don’t share For our affiliates to market to you No We don’t share For nonaffiliates to market to you No We don’t share Questions? Call [PHONE REDACTED] or go to www.fslins.com ---PAGE BREAK--- N-00200 2 93-33087 Rev 0924 Page 2 Who we are Who is providing this notice? Fidelity Security Life Insurance Company and Affiliates including our Administrative, Insurance and Financial Service Providers. What we do How does Fidelity Security Life Insurance Company and Affiliates protect my personal information? To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured files and buildings. These physical, electronic and procedural safeguards were created to protect your information. We also limit employee access as appropriate. How does Fidelity Security Life Insurance Company and Affiliates collect my personal information? We collect your personal information, for example, when you ■ apply for insurance or pay insurance premiums ■ file an insurance claim or give us your contact information ■ show your driver’s license We also collect your personal information from others, such as credit bureaus, affiliates, or other companies. Why can’t I limit all sharing? Federal law gives you the right to limit only ■ sharing for affiliates’ everyday business purposes – information about your creditworthiness ■ affiliates from using your information to market to you ■ sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. Definitions Affiliates Companies related by common ownership or control. They can be financial and nonfinancial companies. ■ Our affiliates include Fidelity Security Life Insurance Company of New York, Fidelity Security Assurance Company, Forrest T. Jones & Company, Inc. and Forrest T. Jones Consulting Company. Nonaffiliates Companies not related by common ownership or control. They can be financial and nonfinancial companies. ■ Fidelity Security Life Insurance Company does not share with nonaffiliates so they can market to you. Joint marketing A formal agreement between nonaffiliated financial companies that together market financial products or services to you. ■ Our joint marketing partners include insurance agencies, broker dealers and investment advisor firms. Other important information ---PAGE BREAK--- N-00210 93-33187 Rev 0126 F I D E L I T Y S E C U R I T Y L I F E I N S U R A N C E C O M P A N Y® 2600 Grand Blvd., Suite 900 Kansas City, Missouri 64108-4626 Phone [PHONE REDACTED] A STOCK COMPANY (Herein Called “the Company”) HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice describes how the Company, (herein referred to as “we”, “our” or protects personal health information we have about you which relates to our medical, dental, vision and prescription drug coverage. Protected Health Information (“PHI”) is individually identifiable information about you. All of the following are examples of PHI: demographic information like your name, address and social security number; health information that relates to your past, present or future physical or mental health that is collected, created or received from you, a health care provider, a health plan, employer or a health care clearinghouse; the providing of health care; or the past, present or future payment for providing health care to you. Our Legal Duty We are required by applicable federal and state laws to maintain the privacy of your PHI. We are required to give you this notice about our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect January 1, 2026, or the date coverage became effective for you, whichever is later, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any time. The new terms of our notice will be effective for all PHI that we maintain, including PHI we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and send the new notice to you at the time of change. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the “Contact Information” provided at the end of this Notice. Uses and Disclosures of Your PHI In conducting our business we may create, receive and maintain PHI records regarding you and the insurance services we provide you. The main reasons for which we may use and may disclose your PHI are to evaluate and process any requests for medical coverage and claims for benefits you may make. The following describe these and other uses and disclosures, together with some examples: For Treatment: We may use or disclose your PHI to facilitate medical treatment by providers. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to treat you. We may request the services of a business associate to assist us in these activities. For Payment: We may use and disclose your PHI to facilitate payment of benefits under your insurance coverage. For example, we might disclose your PHI to determine your eligibility for benefits, to coordinate benefits with other insurance carriers, to examine medical necessity, to obtain payments including obtaining payment under a contract for re-insurance, and related health care data processing, and to issue explanations of benefits. We also may use your PHI to obtain payment from third parties that may be responsible for your premium payments, such as family members. For Health Care Operations: We may use and disclose your PHI as necessary, and as permitted by law, for our health care operations. Health care operations include: rating our risk and determining our premiums for your insurance; (ii) conducting quality assessment and improvement activities; (iii) conducting or arranging for medical review, legal services, audit services, fraud and abuse detection and compliance programs; and (iv) business planning and development. ---PAGE BREAK--- N-00210 93-33187 Rev 0126 On Your Authorization: You may give us written authorization to use your PHI or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. You should understand that we will not be able to take back any disclosures we have already made with authorization. Unless you give us a written authorization, we cannot use or disclose your PHI for any reason except those described in this notice. We also need to obtain your prior written authorization if your PHI relates to notes or where the PHI is to be used for marketing or sales purposes. To Your Family and Friends: We may disclose your PHI to a family member, friend, or other person to the extent necessary to help with your health care or for payment of your health care. We may use or disclose your name, location and general condition or death to notify, or assist in the notification, of (including identifying or locating) a person involved in your care. Before we disclose your PHI to a person involved with your health care or payment for your health care, we will provide you with an opportunity to object to such uses or disclosures. If you are not present, or in the event of your incapacity or an emergency, we will disclose your PHI based on our professional judgment of whether the disclosure would be in your best interest. To Your Employer or Organization Sponsoring Your Health Plan: We may disclose your PHI and the PHI of others enrolled in your group insurance plan to the employer or other organization that sponsors your group insurance plan to permit the plan administrator to perform plan administration functions. We may also disclose summary information about the enrollees in your group insurance plan to the plan administrator to use to obtain premium bids for the health insurance coverage offered through your group insurance plan or to decide whether to modify, amend or terminate your group insurance plan. The summary information we may disclose may summarize claims history, claims expenses, or types of claims experienced by the enrollees in your group insurance plan. The summary information will be stripped of demographic information about the enrollees in the group insurance plan, but the plan administrator may still be able to identify you or other participants in your group health plan from the summary information. We may also disclose enrollment and disenrollment information to either the plan administrator or plan sponsor of your group insurance plan. For Underwriting: We may receive your PHI for underwriting, premium rating or other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits. We will not use or further disclose your PHI for any other purpose, except as required by law, unless the contract of health insurance or health benefits is placed with us, or where we disclose such information to MIB, LLC., a non-profit membership organization of life and health insurance companies, which operates an information exchange on behalf of its members. In those cases, our use and disclosure of your PHI will only be as described in this notice. We are also prohibited from using or disclosing your genetic information for underwriting. For the Public Benefit: We may use or disclose your PHI without your authorization when required or permitted by law for the following purposes deemed in the public interest or benefit: - for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury; - to report adult abuse, neglect, or domestic violence; - to health oversight agencies; - in response to court and administrative orders and other lawful processes; - to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person; - to coroners, medical examiners, and funeral directors; - to organ procurement organizations; - to avert a serious threat to health and safety; - to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities; - to correctional institutions regarding inmates; and - as authorized by state worker’s compensation laws. To Avert a Serious Threat to Health or Safety: We may disclose PHI to avert a serious threat to someone’s health or safety. We may also disclose PHI to federal, state or local agencies engaged in disaster relief, as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations. To Business Associates: Certain aspects and components of our business are preformed through contracts with outside persons or organizations. Examples of these outside persons and organizations include our duly appointed insurance agents, third party administrators, financial auditors, actuarial and underwriting services, reinsurers, legal services, enrollment and billing services, claim payment and medical management services and collection agencies. At times it may be necessary for us to provide your PHI to one or more of these outside persons or organizations who assist us with our payment or health care operations. In all cases, we disclose only the minimum information necessary for these business associates to perform their responsibilities, and we require them to abide by specific HIPAA rules to appropriately safeguard the privacy of your information. ---PAGE BREAK--- N-00210 93-33187 Rev 0126 For Disclosures of PHI Deemed Highly Sensitive or Confidential: For certain kinds of PHI, federal and state law may require enhanced privacy protection. These may include PHI that is About alcohol and drug abuse prevention, treatment and referral; About HIV/AIDS testing, diagnosis or treatment; About genetic testing*; or About notes. If the PHI is subject to enhanced protection, we can only disclose it with your prior written authorization unless specifically permitted or required by law. *FSL does not currently collect, use or disclose genetic or neurotechnology data. Your Rights Regarding PHI That We Maintain About You The following are your various rights as a consumer under HIPAA concerning your PHI. Should you have questions about or wish to exercise a specific right, please contact us in writing using the “Contact Information” provided at the end of this Notice. Right to Inspect and Copy Your PHI: In most cases, you have the right to inspect and/or obtain an electronic or hard copy of the PHI that we maintain about you. You may also send a written request designating another individual to receive your PHI on your behalf. Written requests must be signed and dated by you or your personal representative using the “Contact Information” provided at the end of this Notice. The request must clearly identify the individual to receive your PHI. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. However, certain types of PHI will not be made available for inspection and copying. This includes notes and PHI collected by us in connection with, or in reasonable anticipation of any claim or legal proceeding. In very limited circumstances we may deny your request to inspect and obtain a copy of your PHI. If we do, you may request that the denial be reviewed. The review will be conducted by an individual chosen by us who was not involved in the original decision to deny your request. We will comply with the outcome of that review. Right to List of Disclosures: You have the right to receive a list of instances in which we or our business associates disclosed your PHI for purposes other than for treatment, payment, health care operations, purposes of national security, to law enforcement, to corrections personnel, directly to you or as otherwise authorized by you during the six years prior to the date the accounting is requested. For example, we would account for your PHI or demographic information we disclose during an audit by an insurance department or pursuant to a court order. You must make your request in writing using the “Contact Information” provided at the end of this Notice. Your request should indicate in what form you want the list (for example, paper or electronic). If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on PHI we use or disclose about you for treatment, payment or health care operations, or that we disclose to someone who may be involved in your care or payment for your care, like a family member or friend. While we will consider your request, we are not required to agree to it. If we do agree to it, we will comply with your request. To request a restriction, you must make your request in writing using the “Contact Information” provided at the end of this Notice. In your request, you must tell us what information you want to limit; whether you want to limit our use, disclosure or both; and to whom you want the limits to apply (for example, disclosures to your spouse or parent). We will not agree to restrictions on PHI uses or disclosures that are legally required, or which are necessary to administer our business. Unauthorized Access: You are entitled to receive notification of unauthorized access to your PHI. We maintain physical, electronic and procedural safeguards that are compliant with applicable federal and state privacy laws. However, if your PHI is ever compromised, we will notify you of the incident. Right to Request Confidential Communications: You have the right to request that we communicate with you about PHI in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing using the “Contact Information” provided at the end of this Notice and specify how or where you wish to be contacted. We will accommodate all reasonable requests. Right to Amend Your PHI: If you believe that your PHI is incorrect or that an important part of it is missing, you have the right to ask us to amend your PHI while it is kept by or for us. You must provide your request and your reason for the request in writing using the “Contact Information” provided at the end of this Notice. We may deny your request if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend PHI that: is accurate and complete; (ii) was not created by us, unless the person or entity that created the PHI is no longer available to make the amendment; (iii) is not part of the PHI kept by or for us; or (iv) is not part of the PHI which you would be permitted to inspect and copy. Right to Notification Following a Breach of Unsecured Protected Health Information: We will let you know if a breach occurs that may have compromised the privacy or security of your information. ---PAGE BREAK--- N-00210 93-33187 Rev 0126 Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with us using the “Contact Information” provided at the end of this Notice. All complaints must be submitted in writing. You may 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 (877) 696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. You will not be retaliated against for filing a complaint. Contact Information: If you have questions regarding this Notice or need further assistance regarding this Notice, please contact us at: Contact Office: Fidelity Security Life Insurance Company, HIPAA Customer Service Telephone: [PHONE REDACTED] Fax: [PHONE REDACTED] Address: 2600 Grand Blvd., Suite 900, Kansas City, MO 64108-4626 ---PAGE BREAK--- 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 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 your State 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 dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state 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 aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at 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 plan premiums. The following list of states is current as of July 31, 2025. Contact your State for more information on eligibility – ALABAMA – Medicaid Website: http://myalhipp.com/ Phone: 1-[PHONE REDACTED] ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-[PHONE REDACTED] Email: [EMAIL REDACTED] Medicaid Eligibility: ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP ([PHONE REDACTED]) CALIFORNIA – Medicaid Health Insurance Premium Payment (HIPP) Program Website: http://dhcs.ca.gov/hipp Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] Email: [EMAIL REDACTED] COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado Website: Health First Colorado Member Contact Center: 1-[PHONE REDACTED]/State Relay 711 CHP+: CHP+ Customer Service: 1-[PHONE REDACTED]/State Relay 711 Health Insurance Buy-In Program (HIBI): HIBI Customer Service: 1-[PHONE REDACTED] FLORIDA – Medicaid Website: y.com/hipp/index.html Phone: 1-[PHONE REDACTED] ---PAGE BREAK--- GEORGIA – Medicaid GA HIPP Website: insurance-premium-payment-program-hipp Phone: [PHONE REDACTED], Press 1 GA CHIPRA Website: liability/childrens-health-insurance-program-reauthorization- act-2009-chipra Phone: [PHONE REDACTED], Press 2 INDIANA – Medicaid Health Insurance Premium Payment Program All other Medicaid Website: http://www.in.gov/fssa/dfr/ Family and Social Services Administration Phone: 1-[PHONE REDACTED] Member Services Phone: 1-[PHONE REDACTED] IOWA – Medicaid and CHIP (Hawki) Medicaid Website: Iowa Medicaid I Health & Human Services Medicaid Phone: 1-[PHONE REDACTED] Hawki Website: Hawki - Healthy and Well Kids in Iowa I Health & Human Services Hawki Phone: 1-[PHONE REDACTED] HIPP Website: Health Insurance Premium Payment (HIPP) I Health & Human Services (iowa.gov) HIPP Phone: 1-[PHONE REDACTED] KANSAS – Medicaid Website: Phone: 1-[PHONE REDACTED] HIPP Phone: 1-[PHONE REDACTED] KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: Phone: 1-[PHONE REDACTED] Email: [EMAIL REDACTED] KCHIP Website: Phone: 1-[PHONE REDACTED] Kentucky Medicaid Website: LOUISIANA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-[PHONE REDACTED] (Medicaid hotline) or 1-[PHONE REDACTED] (LaHIPP) MAINE – Medicaid Enrollment Website: _US Phone: 1-[PHONE REDACTED] TTY: Maine relay 711 Private Health Insurance Premium Webpage: Phone: 1-[PHONE REDACTED] TTY: Maine relay 711 MASSACHUSETTS – Medicaid and CHIP Website: Phone: 1-[PHONE REDACTED] TTY: 711 Email: [EMAIL REDACTED] MINNESOTA – Medicaid Website: Phone: 1-[PHONE REDACTED] MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: [PHONE REDACTED] ---PAGE BREAK--- MONTANA – Medicaid Website: Phone: 1-[PHONE REDACTED] Email: [EMAIL REDACTED] NEBRASKA – Medicaid Website: http://www.ACCESSNebraska.ne.gov Phone: 1-[PHONE REDACTED] Lincoln: [PHONE REDACTED] Omaha: [PHONE REDACTED] NEVADA – Medicaid Medicaid Website: Medicaid Phone: 1-[PHONE REDACTED] NEW HAMPSHIRE – Medicaid Website: services/medicaid/health-insurance-premium-program Phone: [PHONE REDACTED] Toll free number for the HIPP program: 1-[PHONE REDACTED], ext. 15218 Email: [EMAIL REDACTED] NEW JERSEY – Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Phone: 1-[PHONE REDACTED] CHIP Premium Assistance Phone: [PHONE REDACTED] CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-[PHONE REDACTED] (TTY: 711) NEW YORK – Medicaid Website: Phone: 1-[PHONE REDACTED] NORTH CAROLINA – Medicaid Website: Phone: [PHONE REDACTED] NORTH DAKOTA – Medicaid Website: Phone: 1-[PHONE REDACTED] OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-[PHONE REDACTED] OREGON – Medicaid and CHIP Website: http://healthcare.oregon.gov/Pages/index.aspx Phone: 1-[PHONE REDACTED] – Medicaid and CHIP Website: medicaid-health-insurance-premium-payment-program- hipp.html Phone: 1-[PHONE REDACTED] CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437) RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 1-[PHONE REDACTED], or [PHONE REDACTED] (Direct RIte Share Line) SOUTH CAROLINA – Medicaid Website: Phone: 1-[PHONE REDACTED] SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-[PHONE REDACTED] ---PAGE BREAK--- TEXAS – Medicaid Website: Health Insurance Premium Payment (HIPP) Program I Texas Health and Human Services Phone: 1-[PHONE REDACTED] UTAH – Medicaid and CHIP Utah’s Premium Partnership for Health Insurance (UPP) Website: Email: [EMAIL REDACTED] Phone: 1-[PHONE REDACTED] Adult Expansion Website: Utah Medicaid Buyout Program Website: CHIP Website: VERMONT– Medicaid Website: Health Insurance Premium Payment (HIPP) Program I Department of Vermont Health Access Phone: 1-[PHONE REDACTED] VIRGINIA – Medicaid and CHIP Website: assistance/famis-select assistance/health-insurance-premium-payment-hipp-programs Medicaid/CHIP Phone: 1-[PHONE REDACTED] WASHINGTON – Medicaid Website: Phone: 1-[PHONE REDACTED] WEST VIRGINIA – Medicaid and CHIP Website: Medicaid Phone: [PHONE REDACTED] CHIP Toll-free phone: (1-[PHONE REDACTED]) WISCONSIN – Medicaid and CHIP Website: Phone: 1-[PHONE REDACTED] WYOMING – Medicaid Website: eligibility/ Phone: 1-[PHONE REDACTED] To see if any other states have added a premium assistance program since July 31, 2025, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-[PHONE REDACTED], Menu Option 4, Ext. 61565 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 [EMAIL REDACTED] and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137 (expires 1/31/2026)