LEGAL NOTICES

The Uniformed Services Employment and Reemployment Rights Act (USERRA)
USERRA provides for, among other employment rights and benefits,
continuation of medical, dental and voluntary vision coverage to a covered
Employee and covered dependents, during a period of active service or
training with any of the Uniformed Services. The Act provides that a covered
Employee may elect to continue such coverages in effect at the time the
Employee is called to active service.
The maximum period of coverage for the Employee and the covered
Employee’s dependents under such an election shall be the lesser of:
the 24-month period beginning on the date the person’s absence
begins; or
the period beginning on the date the covered Employee’s absence
begins and ending on the day after the date on which the covered
Employee fails to apply for or return to a position of employment as follows:
for service of less than 31 days, no later than the beginning of the first full regularly scheduled work
period on the first full calendar day following the completion of the period of service and the expiration
of eight hours after a period allowing for the safe transportation from the place of service to the
covered Employee’s residence or as soon as reasonably possible after such eight-hour period;
for service of more than 31 days but less than 181 days, no later than 14 days after the completion of
the period of service or as soon as reasonably possible after such period;
for service of more than 180 days, no later than 90 days after the completion of the period of service;
or
for a covered Employee who is hospitalized or convalescing from an illness or injury incurred in or
aggravated during the performance of service in the Uniformed Services, at the end of the period that
is necessary for the covered Employee to recover from such illness or injury. Such period of recovery
may not exceed two years.
A covered Employee who elects to continue health plan coverage under the Plan during a period of active
service in the Uniformed Services may be required to pay not more than 102% of the full premium under the
plan associated with such coverage for the employer’s other Employees, except that in the case of a covered
Employee who performs service in the Uniformed Services for less than 31 days, such covered Employee may
not be required to pay more than the Employee share, if any, for such coverage. Continuation coverage cannot
be discontinued merely because activated military personnel receive health coverage as active duty members
of the Uniformed Services, and their family members are eligible to receive coverage under the Department of
Defense’s managed health care program, TRICARE.
In the case of a covered Employee whose coverage under a health plan was terminated by reason of services in
the Uniformed Services, the pre-existing exclusion and waiting period may not be imposed in connection with
the reinstatement of such coverage upon reemployment under this Act. This applies to the covered Employee
who is reemployed and any dependent whose coverage is reinstated. The waiver of the pre-existing exclusion
shall not apply to illness or injury which occurred or was aggravated during performance of service in the
Uniformed Services.
“Uniformed Services” shall include full time and reserve components of the United States Army, Navy, Air
Force, Marines, Coast Guard, Army National Guard, the commissioned corps of the Public Health Service, and
any other category of persons designated by the President in time of war or emergency.
If you are a covered Employee called to a period of active service in the Uniformed Service, you should check
with the Plan Administrator for a more complete explanation of your rights and obligations under USERRA. In
the event of a conflict between this provision and USERRA, the provisions of USERRA, as interpreted by us or
your former employer, will apply.
- 43 -

LEGAL NOTICES

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).
ALABAMA – Medicaid
FLORIDA – Medicaid
Website: http://myalhipp.com/
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-855-692-5447
Phone: 1-877-357-3268
ALASKA – Medicaid
GEORGIA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://dch.georgia.gov/medicaid
Website: http://myakhipp.com/
- Click on Health Insurance Premium Payment (HIPP)
Phone: 1-866-251-4861
Phone: 404-656-4507
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid
ARKANSAS – Medicaid
INDIANA – Medicaid
Website: http://myarhipp.com/
Healthy Indiana Plan for low-income adults 19-64
Phone: 1-855-MyARHIPP (855-692-7447)
Website: http://www.hip.in.gov
Phone: 1-877-438-4479
All other Medicaid
Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
COLORADO – Medicaid
IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Website: http://www.dhs.state.ia.us/hipp/
Medicaid Customer Contact Center: 1-800-221-3943
Phone: 1-888-346-9562
KANSAS – Medicaid
NEW HAMPSHIRE – Medicaid
Website: http://www.kdheks.gov/hcf/
Website: www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 1-785-296-3512
Phone: 603-271-5218
KENTUCKY – Medicaid
NEW JERSEY – Medicaid and CHIP
Website: http://chfs.ky.gov/dms/default.htm
Medicaid Website:
Phone: 1-800-635-2570
http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
LOUISIANA – Medicaid
NEW YORK – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-888-695-2447
Phone: 1-800-541-2831


- 44 -

LEGAL NOTICES

MAINE – Medicaid
NORTH CAROLINA – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Website: http://www.ncdhhs.gov/dma
Phone: 1-800-442-6003
Phone: 919-855-4100
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
NORTH DAKOTA – Medicaid
Website: http://www.mass.gov/MassHealth
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-462-1120
Phone: 1-844-854-4825
MINNESOTA – Medicaid
OKLAHOMA – Medicaid and CHIP
Website: http://mn.gov/dhs/ma/
Website: http://www.insureoklahoma.org
Phone: 1-800-657-3739
Phone: 1-888-365-3742
MISSOURI – Medicaid
OREGON – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Website: http://healthcare.oregon.gov/Pages/index.aspx
Phone: 573-751-2005
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
MONTANA – Medicaid
PENNSYLVANIA – Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Website: http://www.dhs.pa.gov/hipp
Phone: 1-800-694-3084
Phone: 1-800-692-7462
NEBRASKA – Medicaid
RHODE ISLAND – Medicaid
Website:
Website: http://www.eohhs.ri.gov/
http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebras
ka_index.aspx
Phone: 401-462-5300
Phone: 1-855-632-7633
NEVADA – Medicaid
SOUTH CAROLINA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Website: http://www.scdhhs.gov
Medicaid Phone: 1-800-992-0900
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
WASHINGTON – Medicaid
Website: http://dss.sd.gov Phone: 1-888-828-0059
Website: http://www.hca.wa.gov/free-or-low-cost-health- care/program-
administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid
WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/ Phone: 1-800-440-0493
Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Page s/default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP
WISCONSIN – Medicaid and CHIP
Website:
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-
362-3002
Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid
WYOMING – Medicaid
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
VIRGINIA – Medicaid and CHIP

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP
Phone: 1-855-242-8282



- 45 -

LEGAL NOTICES

WOMEN’S HEALTH AND CANCER RIGHTS ACT

All health plans offered through the CHEIBA Trust provide coverage for certain reconstructive services under
the Women’s Health and Cancer Rights Act. These services include:

reconstruction of the breast upon which a mastectomy has been performed
surgery/reconstruction of the other breast to produce a symmetrical appearance
prostheses
treatment related to physical complications during all stages of mastectomy, including lymph edemas

Refer to your certificate of coverage for specific information on coverage. The plans may apply deductibles and
copayments consistent with other coverage provided.

NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT

Group health plans and health insurance issuers generally may not, under Federal law, 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 section. However, Federal law generally
does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and
issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance
issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

HIPAA SPECIAL ENROLLMENT NOTICE
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health
insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if
you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward
your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or
your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption,
you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days
after the marriage, birth, adoption, or placement for adoption.

HIPAA PRIVACY AND SECURITY

The Health Insurance Portability and Accountability Act of 1996 deals with how an employer can enforce
eligibility and enrollment for health care benefits, as well as ensuring that protected health information which
identifies you is kept private. You have the right to inspect and copy protected health information that is
maintained by and for the plan for enrollment, payment, claims and case management. If you feel that
protected health information about you is incorrect or incomplete, you may ask your benefits administrator to
amend the information. The Notice of Privacy Practices has recently been updated. For a full copy of the Notice
of Privacy Practices, describing how protected health information about you may be used and disclosed and
how you can get access to the information, contact your Human Resources department.


- 46 -

LEGAL NOTICES

CONTINUATION COVERAGE RIGHTS UNDER COBRA
You are receiving this notice because
you are covered under the CHEIBA
The right to COBRA continuation coverage was created by a federal law,
Trust (the Plan). This notice contains
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
important information about your right
COBRA continuation coverage may become available to you and your
to continue your health care coverage
dependents that are covered under the Plan when you would otherwise
in the CHEIBA Trust Employee Benefit
lose your group health coverage. This notice gives only a summary of
Plan as well as other health coverage
your COBRA continuation coverage rights. For more information about
alternatives that may be available to
your rights and obligations under the Plan and under federal law, you
you through the Health Insurance
should review the Plan's Summary Plan Description or get a copy of the
Marketplace. This notice generally
Plan Document from the HealthSmart COBRA Administrator listed below.
explains COBRA continuation
COBRA continuation coverage for the Plan is administered by:
coverage, when it may become

HealthSmart
available to you and your family and

10303 E. Dry Creek Road, Suite 200
what you need to do to protect the

Englewood, CO 80112
right to receive it.

1-800-423-4445

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 monthly 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 does not accept late enrollees.

What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because
of a life event known as a “qualifying event.” Specific qualifying events are listed later in the notice. COBRA
continuation coverage must be offered to each person who is a “qualified beneficiary”. A qualified beneficiary
is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of
qualifying event, Employees, spouses of Employees, Civil Union Partners, and dependent children may be
qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must
pay for COBRA continuation coverage.

If you are an Employee, you will become a qualified beneficiary if you will lose your coverage under the Plan
because either one of the following qualifying events occurs:
1) Your hours of employment are reduced, or
2) Your employment ends for any reason other than gross misconduct.

If you are the spouse or Civil Union Partner of an Employee, you will become a qualified beneficiary if you will
lose your coverage under the Plan because any one of the following qualifying events occurs:
1) The Employee dies;
2) The Employee’s hours of employment are reduced;
3) The Employee’s employment ends for any reason other than gross misconduct;
4) The Employee becomes enrolled in Medicare (Part A, Part B, or both);
5) You become divorced or legally separated from your spouse; or

6) The civil union is dissolved.

Your dependent children and the dependent children of a Civil Union Partner will become qualified
beneficiaries if they will lose coverage under the Plan because any one of the following qualifying events
occurs:
1) The parent/Employee dies;
2) The parent/Employee's hours of employment are reduced;
3) The parent/Employee's employment ends for any reason other than his or her gross misconduct;
4) The parent/Employee becomes enrolled in Medicare (Part A, Part B, or both);
5) The parents become divorced or legally separated;
6) The child stops being eligible for coverage under the plan as a “dependent child”; or
7) The civil union is dissolved.


- 47 -

LEGAL NOTICES

When is COBRA Coverage Available?
The Plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been
notified in a timely manner that a qualifying event has occurred. When the qualifying event is the end of
employment or reduction of hours of employment, death of the Employee, or enrollment of the Employee in
Medicare (Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.

Employees Must Give Notice of Some Qualifying Events
For the 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. The Plan requires
you to notify the Plan Administrator in writing within 60 days after the later of the qualifying event or the loss
of coverage.

IF YOU, YOUR SPOUSE, CIVIL UNION PARTNER, OR DEPENDENT CHILDREN DO NOT ELECT CONTINUATION
COVERAGE WITHIN THIS 60-DAY ELECTION PERIOD, YOU WILL LOSE YOUR RIGHT TO ELECT CONTINUATION
COVERAGE.

How is COBRA 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 Civil Union Partners, and parents may elect COBRA continuation coverage on behalf of
their children. For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation
coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would
otherwise have been lost, depending on the nature of the Plan.

How long will COBRA Coverage Last?
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death
of the Employee, your divorce or legal separation, or a dependent child losing eligibility as a dependent child,
COBRA continuation coverage lasts for up to 36 months.

When the qualifying event is the end of employment or reduction of the Employee's hours of employment, and
the Employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA
continuation coverage for qualified beneficiaries other than the Employee lasts until 36 months after the date
of Medicare entitlement. For example, if a covered Employee becomes entitled to Medicare eight months
before the date on which his employment terminates, COBRA continuation coverage for his spouse and
children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the
date of the qualifying event (36 months minus eight months).

Otherwise, when the qualifying event is the end of employment or reduction of the Employee's hours of
employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two
ways in which this 18-month period of COBRA continuation coverage can be extended.

Disability Extension of 18-month Period of Continuation Coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration
or PERA to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family
may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total
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 continuation
coverage. This notice should be sent to the HealthSmart COBRA Administrator.


- 48 -

LEGAL NOTICES


Second Qualifying Event Extension of 18-month Period of Continuation Coverage
If your family experiences another qualifying event while receiving COBRA continuation coverage, the
spouse and dependent children in your family can get additional months of COBRA continuation coverage,
up to a maximum of 36 months. This extension is available to the spouse and dependent children if the
former Employee dies, or gets divorced or legally separated. The extension is also available to a dependent
child when that child stops being eligible under the Plan as a dependent child, but only if the event would
have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event
not occurred. In all of these cases, you must make sure that the Plan Administrator is notified of the
second qualifying event within 60 days of the second qualifying event. This notice must be sent to the
HealthSmart COBRA Administrator.
Continuation coverage will be terminated before the end of the maximum period if:
any required premium is not paid in full on time,
a qualified beneficiary first becomes covered, after electing continuation coverage, under another
group health plan,
a qualified beneficiary first becomes entitled to Medicare benefits (under Part A, Part B, or both) after
electing continuation coverage, or
the employer ceases to provide any group health plan for its employees.

Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a
participant or beneficiary not receiving continuation coverage (such as fraud).
Domestic Partners
All eligibility and coverage for domestic partners and the children of domestic partners was closed effective
January 1, 2016, provided however that coverage for any domestic partner and the children of the domestic
partnership is effective through December 31, 2016, if such coverage was in effect on December 31, 2015.
After December 31, 2016, all coverage for domestic partners and the children of domestic partners is
terminated.

The CHEIBA Trust and the CHEIBA Trust Members approved 18 months of COBRA coverage to domestic
partners and the children of domestic partners whose coverage is in effect on December 31, 2016.

Domestic partners and children of domestic partners who are covered under a CHEIBA medical, dental or
vision plan will receive a Cobra Election Notice with the information that is necessary to maintain coverage
for up to 18 months.


If You Have Questions
If you have questions about your COBRA continuation coverage, you should contact the HealthSmart COBRA
Administrator at 1-800-423-4445 or send an email to askcobra@healthsmart.com.

COBRA Premium Payment Guidelines
Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The
amount a qualified beneficiary may be required to pay may not exceed 102% of the cost to the group health
plan (including both employer and employee contributions) for coverage of a similarly situated plan participant
or beneficiary who is not receiving continuation coverage. The required payment guidelines will be provided at
the time of COBRA enrollment.
If you elect continuation coverage, you do not have to send any payment with the Election Form. However,
you must make your first payment for continuation coverage not later than 45 days after the date of your
election. (This is the date the Election Notice is postmarked, if mailed) If you do not make your first payment
for continuation coverage in full no later than 45 days after the date of your election, you will lose all
continuation coverage rights under the Plan. You are responsible for making sure that the amount of your first
payment is correct. You may contact the HealthSmart COBRA Administrator to confirm the correct amount of
your first payment.
After you make your first payment for continuation coverage, you will be required to make periodic payments
for each subsequent coverage period. The periodic payments may be made on a monthly basis. After the first
payment, the periodic payments are due on the first of the month.


- 49 -

LEGAL NOTICES

Although periodic payments are due on the dates shown above, you will be given a grace period of 30 days
after the first day of the coverage period to make each periodic payment. Your continuation coverage will be
provided for each coverage period as long as payment for that coverage period is made before the end of the
grace period for that payment. If you fail to make a periodic payment before the end of the grace period for
that coverage period, you will lose all rights to continuation coverage under the Plan.
The monthly premium for continuation of the Health Care Flexible Spending Account is based on the annual
amount you choose to contribute to the account and the number of months remaining under COBRA coverage
during the period for which the employee made the election. The Plan may charge additional administrative
fees for continued participation.

Keep Your Plan Administrator Informed of Address Changes
In order to protect your family's rights, you should keep the Plan Administrator informed of 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.

Important HIPAA Information:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes some provisions that may
affect decisions you make about your participation in the Group Health Plan under the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA). These provisions are as follows:
1) Under HIPAA, if a qualified beneficiary is determined by the Social Security Administration to be disabled
under the Social Security Act at any time during the first 60 days of COBRA coverage, the 11-month
extension is available to all individuals who are qualified beneficiaries due to the termination or reduction
in hours of employment. The disabled individual can be a covered Employee or any other qualified
beneficiary.

However, to be eligible for the 11-month extension, affected individuals must still comply with the
notification requirements.

2) A child that is born to or placed for adoption with the covered Employee during a period of COBRA
coverage will be eligible to become a qualified beneficiary. In accordance with the terms of the employer's
group health plan(s) and the requirements of Federal law, these qualified beneficiaries can be added to
COBRA coverage upon proper notification to the Plan Administrator of the birth or adoption.

If you have any questions about COBRA, or if you have changed marital status, or you or your spouse have
changed addresses, please contact the HealthSmart COBRA Administrator or send an email to
askcobra@healthsmart.com.

- 50 -

LEGAL NOTICES

IMPORTANT NOTICE FROM THE CHEIBA TRUST
ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND
MEDICARE (CREDITABLE COVERAGE NOTICE)

Please read this notice carefully and keep it where you can find it. This notice has information about your
current prescription drug coverage through the CHEIBA Trust and prescription drug coverage available for
people with Medicare. It also explains the options you have under Medicare prescription drug coverage and
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. At the end of this
notice is information about where you can get help to make decisions about your prescription drug coverage.
Please share this information with any other family member who is covered under the plan and who may be
eligible for Medicare Part D.

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through
Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug
coverage. All Medicare prescription 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 CHEIBA Trust has determined that the prescription drug coverage offered through the CHEIBA Trust
for the HMO/POS, PRIME Blue Priority PPO, Blue Priority HMO, Lumenos 2500 and Custom Plus plans is,
on average for all plan participants, expected to pay out as much as the 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 enroll in a Medicare prescription drug plan.
Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and
each year from October 15th through December 7th. However, if you lose your current creditable prescription
drug coverage, through no fault of your own, you will be eligible for your two-month Special Enrollment Period
(SEP) to join a Medicare drug plan.

If you decide to join a Medicare drug plan, your CHEIBA Trust coverage will be affected.

If you do decide to join a Medicare drug plan and drop your CHEIBA Trust prescription drug coverage, be
aware that you and your dependents may not be able to get this coverage back.

You should also know that if you drop or lose your coverage with the CHEIBA Trust 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 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, please reference the
Multi-Option Plan Summary included in the back pocket of the Benefit Booklet or contact your Human
Resources/Benefits Office for further information. NOTE: You will receive this notice annually and at other
times in the future such as before the next period you can join a Medicare drug plan, and if this coverage
through the CHEIBA Trust changes. You also may request a copy of this notice at any time.
- 51 -

LEGAL NOTICES

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 prescription 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 the "Medicare & You"
handbook for their telephone number) for personalized help,
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for Medicare prescription drug coverage is
available. Information about this extra help is available from the Social Security Administration (SSA) on the
web at www.socialsecurity.gov, or you can call them at 1-800-772-1213 (TTY 1-800-325-0778).

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:
9/19/2016
Date:
9/19/2016
Name of Entity/Sender:
Adams State University
Name of Entity/Sender:
Fort Lewis College
Contact--Position/Office:
Human Resources/ Benefits Office
Contact--Position/Office:
Human Resources/ Benefits Office
Address:
208 Edgemont Blvd.
Address:
1000 Rim Drive
Alamosa, CO 81101
Durango, CO 81301-3999
Phone Number:
719-587-7990
Phone Number:
970-247-7428
Date:
9/19/2016
Date:
9/19/2016
Name of Entity/Sender:
Auraria Higher Education
Name of Entity/Sender:
Metropolitan State University of
Center
Denver
Contact--Position/Office:
Human Resources/ Benefits Office
Contact--Position/Office:
Human Resources/ Benefits Office
Address:
Campus Box C, PO Box 173361
Address:
Campus Box 47, PO Box 173362
1201-5th Street, #370
Student Success Building
Denver, CO 80217-3361
890 Auraria Parkway, Suite 310
Denver, CO 80217-3362
Phone Number:
303-556-3384
Phone Number:
303-556-3120
Date:
9/19/2016
Date:
9/19/2016
Name of Entity/Sender:
Colorado School of Mines
Name of Entity/Sender:
University of Northern Colorado
Contact--Position/Office:
Human Resources/ Benefits Office
Contact--Position/Office:
Human Resources/ Benefits Office
Address:
1500 Illinois Street
Address:
Carter Hall, Rm. 2002
Golden, CO 80401
Campus Box 54
Greeley, CO 80639
Phone Number:
303-273-3052
Phone Number:
970-351-2718
Date:
9/19/2016
Date:
9/19/2016
Name of Entity/Sender:
Colorado State University -
Name of Entity/Sender:
Western State Colorado
Pueblo
University
Contact--Position/Office:
Human Resources/ Benefits Office
Contact--Position/Office:
Human Resources/ Benefits Office
Address:
2200 Bonforte Boulevard
Address:
600 N. Adams Street
Pueblo, CO 81001
Taylor Hall, Room 321
Gunnison, CO 81231
Phone Number:
719-549-2441
Phone Number:
970-943-3140
Date:
9/19/2016


Name of Entity/Sender:
Colorado State University –


Global Campus
Contact--Position/Office:
Human Resources/ Benefits Office


Address:
7800 East Orchard Road, #200


Greenwood Village, CO 80111
Phone Number:
720-279-0168




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