Medical

- your employment with the Employer ends for any reason other than gross misconduct; or
- your regularly scheduled work hours are reduced so that you no longer meet the Plan’s eligibility requirements.

In addition, COBRA coverage is available to your covered dependents if their coverage would otherwise end because:

- you die, get divorced, become legally separated; or
- you become entitled to Medicare coverage; or
- your dependent child ceases to be eligible for Plan coverage (for example, due to age or loss of full-time student status).

You will be provided with the proper forms, information, and costs upon leaving your employment with College Preparatory.

SPECIAL NOTICES

HIPAA

Health Insurance Portability and Accountability Act (HIPAA) of 1996 Notice

Special Enrollment Information

This information is being provided to you pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996. It contains some special information regarding your rights to enroll for coverage under the medical plan in the future. This information is very important if you are currently declining coverage under the medical plan for yourself or for any of your dependents. We are required to provide you with this notice in order to comply with HIPAA.

If You are Declining Coverage Now

If you have decided to decline coverage for yourself or for any of your dependents (including your spouse), you may be able to enroll yourself and/or your dependents in this plan later, under some circumstances, without waiting for an open enrollment period.

Special Enrollment Allowed

You can enroll yourself and your dependents in this plan without waiting for an open

enrollment period if:

1. You decline coverage under this plan because you have other health care coverage, then you lose the other coverage because you are no longer eligible or because the employer failed to pay the required premium. In such cases, you must enroll in this plan within 31 days after losing the other coverage.

2. You decline coverage under this plan and then a new dependent is added to your family due to marriage, birth, adoption, or placement or adoption. In such cases, you must enroll in this plan (or add your new dependent) within 31 days after the marriage, birth, adoption, or placement for adoption.

Any request must be consistent with the change in family status. For example, the birth or adoption of a child would permit enrollment in or change to family coverage.

Other Late Entrants

If you decide not to enroll in this plan now and then want to enroll later, you must qualify for special enrollment as described above. If you do not qualify for special enrollment, you will have to wait until an open enrollment period.

For more information, please contact your PHR administrator.

WHCRA

Women’s Health and Cancer Rights Act (WHCRA) Notice

Re: Health Plan Coverage for Reconstructive Breast Surgery under The Women’s Health and

Cancer Rights Act of 1998

Since 1998, Congress has required that all health plans cover reconstructive surgery following a mastectomy. When a covered individual receives benefits for a mastectomy and decides to have breast reconstruction based on consultation between the attending physician and the patient, the health plan must cover:

reconstruction of the breast on which the mastectomy was performed;
surgery and reconstruction of the other breast to produce symmetrical appearance; and
prostheses and physical complications of all stages of mastectomy, including lumphedema.

Our plan complies with the Federal mandate. This coverage will be subject to all other Plan provisions.

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