EMPLOYEE RIGHTS
PAID SICK LEAVE AND EXPANDED FAMILY AND MEDICAL LEAVE
UNDER THE FAMILIES FIRST CORONAVIRUS RESPONSE ACT
WAGE AND HOUR DIVISION
UNITED STATES DEPARTMENT OF LABOR
WH1422 REV 03/20
For additional information

1-866-487-9243

dol.gov/agencies/whd
1. 

2. 

3. 

4. 

ENFORCEMENT





5. 


6. 


Families First Coronavirus Response Act (FFCRA or Act) 


PAID LEAVE ENTITLEMENTS
Generally, employers covered under the Act must provide employees:








ELIGIBLE EMPLOYEES


Employees who have been employed for at least 30 days

QUALIFYING REASONS FOR LEAVE RELATED TO COVID-19

telework
DERECHOS DEL EMPLEADO
LICENCIA POR ENFERMEDAD PAGADA Y EXPANSION DE LICENCIA
FAMILIAR Y POR ENFERMEDAD BAJO LEY FAMILIAS PRIMERO
DE RESPUESTA AL CORONAVIRUS
DIVISION DE HORAS Y SALARIOS
DEPARTAMENTO DE TRABAJO DE ESTADOS UNIDOS
WH1422 SPA REV 03/20
Para información adicional
o para presentar una queja:
1-866-487-9243
TTY: 1-877-889-5627
dol.gov/agencies/whd
1. está sujeto a orden de cuarentena o aislamiento
Federal, Estatal, o local relacionada al COVID-19;
2. ha sido instruido por un proveedor de salud que se
ponga en auto-cuarentena por COVID-19;
3. está experimentando síntomas de COVID-19 y está
solicitando diagnóstico médico;
4. está cuidando a una persona sujeta a una orden
descrita en (1) o en auto-cuarentena descrita en (2);
CUMPLIMIENTO
La División de Horas y Salarios (WHD) del Departamento de Trabajo de EE.UU. tiene la autoridad de investigar y hacer
que se cumpla la FFCRA. Los empleadores no podrán expulsar, disciplinar, o discriminar de ningún modo a un empleado
que legalmente hace uso de su derecho a licencia laboral pagada o a extensión de licencia familiar y por enfermedad
bajo FFCRA, presenta una queja, o inicia un procedimiento bajo o relativo a esta Ley. Los empleadores que violen las
provisiones de la FFCRA serán objeto de multas y medidas de cumplimiento por la WHD.
5. está cuidando a un hijo cuya escuela o lugar de
cuidados está cerrado (o cuidados infantiles no
están disponibles) por razones de COVID-19; o
6. está experimentando otras condiciones

el Secretario de Salud y Servicios Humanos.
La Ley Familias Primero de Respuesta al Coronavirus (FFCRA o Ley) requiere que ciertos empleadores den
a empleados licencias laboral pagadas o expansión de licencia familiar y por enfermedad por razones relativas al
COVID-19. Estas provisiones aplicarán desde abril 1 hasta diciembre 31 del 2020.
DERECHOS A LICENCIA LABORAL PAGADA
En general, los empleadores cubiertos bajo la Ley deben proveer a empleados:
Hasta 2 semanas (80 horas, o el equivalente de dos semanas de un empleado a tiempo parcial) de licencia por
enfermedad pagada en base a su mayor tasa regular de pago, o el salario mínimo estatal o federal aplicable, de la
siguiente manera:


Hasta 12 semanas de licencia por enfermedad pagada y expansión de licencia familiar y por enfermedad pagada

Un empleado a tiempo parcial es elegible a licencia por las horas que trabajaría durante ese periodo.
EMPLEADOS ELEGIBLES
En general, empleados de empleadores del sector privado con menos de 500 trabajadores, y de ciertos empleadores del
sector público, son elegibles a hasta dos semanas de licencia pagada total o parcialmente por enfermedad por razones
de COVID-19 (ver abajo). Empleados que hayan estado en nómina al menos 30 días anteriores a su solicitud de licencia
podrán ser elegibles a hasta 10 semanas adicionales de expansión pagada parcialmente de licencia familiar y por
enfermedad por razón #5.
RAZONES CALIFICABLES A LICENCIA RELACIONADA A COVID-19
Un empleado tiene derecho a tomar licencia laboral relacionada a COVID-19 si no le es posible trabajar, incluyendo
imposibilidad de hacer teletrabajo, porque el empleado:
New
Health Insurance Marketplace Coverage
Options
and Your
Health Coverage
PART A: General
Information
ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ
:
͑ΥΙΖ͑͹ΖΒΝΥΙ͑
ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑
ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟
͑
What is the Health Insurance Marketplace?
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑
;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑
ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟΀ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑
ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑΀ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡
Can I Save Money on my Health Insurance Premiums in the Marketplace?
ΊΠΦ͑ΞΒΪ͑΢ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑
ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑
ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑
ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟͹ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑
ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑
ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑
ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑
ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑
ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͟
͢
͑
͑
ͿΠΥΖͫ
͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑
ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑
ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑
ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞
ΥΒΩ͑ΓΒΤΚΤ͑͟
͑
How Can I Get More Information?
ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑
ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟
͑
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑
;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟΁ΝΖΒΤΖ͑ΧΚΤΚΥ͑
͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ
͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑
ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑͹ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟
͑͢
ͲΟ͑
ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑
ΚΗ͑ ΥΙΖ͑
ΡΝΒΟ͘Τ͑
ΤΙΒΣΖ͑ΠΗ͑
ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑
ΓΪ͑
ΥΙΖ͑ΡΝΒΟ͑
ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑
ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑
ΠΗ͑
ΤΦΔΙ͑ΔΠΤΥΤ͟
͑
Form Approved
OMB No. 1210-
0149
H[SLUHV5312020
ECC Human Resources Benefits Department - 847-214-7988 or 847-214-7125
PART B: Information About Health Coverage Offered by Your Employer
΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑
ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑
ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟
3.
Employer name
4.
Employer Identification Number (EIN)
5.
Employer address
6.
Employer phone number
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City
8.
State
9. ZIP
code
10.
Who can we contact about employee health coverage at this job?
11. Phone number (if different from above) 12. Email address
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͹ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑
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ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑
ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑
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΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑
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x
ΈΚΥΙ͑ΣΖΤΡΖΔΥ͑ΥΠ͑ΕΖΡΖΟΕΖΟΥΤͫ͑
ΈΖ͑ΕΠ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ͶΝΚΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟΥΤ͑ΒΣΖͫ͑
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ΈΖ͑ΕΠ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟
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ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑
ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟
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͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑
ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝
ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑
ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑
ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑΢ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟
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ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝
͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ
ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟͹ΖΣΖ͘Τ͑ΥΙΖ͑
ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑
͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ
͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑
ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟
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Elgin Community College District #509
36-2600170
1700 Spartan Drive
847-214-7988 / 847-214-7125
Elgin
IL
Human Resources - Benefits
tmenendez@elgin.edu / lgemelli@elgin.edu
A full-time employee who is regularly scheduled to work a minimum of 35/40 hours per week and who is on the permanent payroll of the Employer.
Spouse, Civil Union Partner, Domestic Partner, Children
Nuevas opciones de cobertura en el mercado de
seguros médicos y su cobertura médica
PARTE A: Información general
ʹΦΒΟΕΠ͑ΖΟΥΣΖΟ͑ΖΟ͑ΧΚΘΖΟΔΚΒ͑ΝΒΤ͑ΡΒΣΥΖΤ͑ΔΝΒΧΖ͑ΕΖ͑ΝΒ͑ΝΖΪ͑ΕΖ͑ΤΒΝΦΕ͑ΖΟ͑ΖΝ͑ͣͥ͑͢͡͝ΙΒΓΣϱ͑ΦΟΒ͑ΟΦΖΧΒ͑ΗΠΣΞΒ͑ΕΖ͑ΒΕ΢ΦΚΣΚΣ͑
ΤΖΘΦΣΠΤ͑ΞϹΕΚΔΠΤͫ͑Β͑ΥΣΒΧϹΤ͑ΕΖΝ͑ΞΖΣΔΒΕΠ͑ΕΖ͑ΤΖΘΦΣΠΤ͑ΞϹΕΚΔΠΤ͑͟Ͳ͑ΗΚΟ͑ΕΖ͑ΒΪΦΕΒΣΝΖ͑ΞΚΖΟΥΣΒΤ͑ΖΧΒΝΦΒ͑ΝΒΤ͑ΠΡΔΚΠΟΖΤ͑ΡΒΣΒ͑
ΦΤΥΖΕ͑Ϊ͑ΤΦ͑ΗΒΞΚΝΚΒ͑͝ΖΤΥΖ͑ΒΧΚΤΠ͑ΓΣΚΟΕΒ͑ΚΟΗΠΣΞΒΔΚЃΟ͑ΓϱΤΚΔΒ͑ΤΠΓΣΖ͑ΖΝ͑ΟΦΖΧΠ͑ΞΖΣΔΒΕΠ͑Ϊ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑ΓΒΤΒΕΒ͑ΖΟ͑
ΖΝ͑ΖΞΡΝΖΠ͑΢ΦΖ͑ΓΣΚΟΕΒ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑͑͟
¿Qué es el mercado de seguros médicos?
ͶΝ͑ΞΖΣΔΒΕΠ͑ΖΤΥϱ͑ΕΚΤΖЁΒΕΠ͑ΡΒΣΒ͑ΒΪΦΕΒΣΝΖ͑Β͑ΖΟΔΠΟΥΣΒΣ͑ΦΟ͑ΤΖΘΦΣΠ͑ΞϹΕΚΔΠ͑΢ΦΖ͑ΤΒΥΚΤΗΒΘΒ͑ΤΦΤ͑ΟΖΔΖΤΚΕΒΕΖΤ͑Ϊ͑ΤΖ͑ΒΛΦΤΥΖ͑
Β͑ΤΦ͑ΡΣΖΤΦΡΦΖΤΥΠ͑͟ͶΝ͑ΞΖΣΔΒΕΠ͑ΠΗΣΖΔΖ͑ΠΡΔΚΠΟΖΤ͑ΕΖ͑ΔΠΞΡΣΒ͑ΖΟ͑ΦΟ͑ΤΠΝΠ͑ΤΚΥΚΠ͑͝ΡΒΣΒ͑ΓΦΤΔΒΣ͑Ϊ͑ΔΠΞΡΒΣΒΣ͑ΠΡΔΚΠΟΖΤ͑ΕΖ͑
ΤΖΘΦΣΠΤ͑ΞϹΕΚΔΠΤ͑ΡΣΚΧΒΕΠΤ͑͟΅ΒΞΓΚϹΟ͑ΖΤ͑ΡΠΤΚΓΝΖ͑΢ΦΖ͑ΤΖΒ͑ΖΝΖΘΚΓΝΖ͑ΡΒΣΒ͑ΦΟ͑ΟΦΖΧΠ͑ΥΚΡΠ͑ΕΖ͑ΔΣϹΕΚΥΠ͑ΥΣΚΓΦΥΒΣΚΠ͑΢ΦΖ͑ΣΖΕΦΔΖ͑
ΤΦ͑ΡΣΚΞΒ͑ΞΖΟΤΦΒΝ͑ΕΖ͑ΚΟΞΖΕΚΒΥΠ͑͑͟ͶΝ͑ΡΖΣΚΠΕΠ͑ΕΖ͑ΚΟΤΔΣΚΡΔΚЃΟ͑ΡΒΣΒ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑ΕΖ͑ΤΖΘΦΣΠ͑ΞϹΕΚΔΠ͑Β͑ΥΣΒΧϹΤ͑ΕΖΝ͑
ΞΖΣΔΒΕΠ͑ΔΠΞΚΖΟΫΒ͑ΖΟ͑ΠΔΥΦΓΣΖ͑ΕΖΝ͑ͣͤ͑͢͡ΡΒΣΒ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑΢ΦΖ͑ΔΠΞΚΖΟΫΒ͑ΖΝ͑͢͟ϊ͑ΕΖ͑ΖΟΖΣΠ͑ΕΖΝ͑ͣͥ͑͑͢͟͡
¿Puedo ahorrar dinero en las primas del seguro médico que ofrece el mercado?
ͶΤ͑ΡΠΤΚΓΝΖ͑΢ΦΖ͑ΥΖΟΘΒ͑ΝΒ͑ΠΡΠΣΥΦΟΚΕΒΕ͑ΕΖ͑ΒΙΠΣΣΒΣ͑ΕΚΟΖΣΠ͑Ϊ͑ΣΖΕΦΔΚΣ͑ΤΦ͑ΡΣΚΞΒ͑ΞΖΟΤΦΒΝ͑͝ΡΖΣΠ͑ΤΠΝΠ͑ΤΚ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑ΟΠ͑
ΠΗΣΖΔΖ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑͑Φ͑ΠΗΣΖΔΖ͑ΦΟΒ͑ΔΠΓΖΣΥΦΣΒ͑΢ΦΖ͑ΟΠ͑ΔΦΞΡΝΖ͑ΔΠΟ͑ΕΖΥΖΣΞΚΟΒΕΒΤ͑ΟΠΣΞΒΤ͑͟ͽΠΤ͑ΒΙΠΣΣΠΤ͑ΖΟ͑ΝΒ͑
ΡΣΚΞΒ͑ΡΠΣ͑ΝΒ͑ΔΦΒΝ͑ΡΦΖΕΖ͑ΤΖΣ͑ΖΝΖΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟ͑ΕΖ͑ΝΠΤ͑ΚΟΘΣΖΤΠΤ͑ΕΖ͑ΤΦ͑ΗΒΞΚΝΚΒ͑͑͟
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¿La cobertura médica del empleador afecta la elegibilidad para los ahorros en la prima a través del
mercado?
΄Ͻ͑͟΄Κ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑ΓΣΚΟΕΒ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑΢ΦΖ͑ΔΦΞΡΝΖ͑ΔΠΟ͑ΕΖΥΖΣΞΚΟΒΕΒΤ͑ΟΠΣΞΒΤ͑͝ΟΠ͑ΤΖΣϱ͑ΖΝΖΘΚΓΝΖ͑ΡΒΣΒ͑ΦΟ͑
ΔΣϹΕΚΥΠ͑ΥΣΚΓΦΥΒΣΚΠ͑Β͑ΥΣΒΧϹΤ͑ΕΖΝ͑ΞΖΣΔΒΕΠ͑Ϊ͑ΖΤ͑ΡΠΤΤΚΓΝΖ͑΢ΦΖ͑ΕΖΤΖΖ͑ΚΟΤΔΣΚΓΚΣΤΖ͑ΖΟ͑ΖΝ͑ΡΝΒΟ͑ΕΖ͑ΤΒΝΦΕ͑ΕΖ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑͟ͿΠ͑
ΠΓΤΥΒΟΥΖ͑͝ΖΤ͑ΡΠΤΚΓΝΖ͑΢ΦΖ͑ΤΖΒ͑ΖΝΖΘΚΓΝΖ͑ΡΒΣΒ͑ΦΟ͑ΔΣϹΕΚΥΠ͑ΥΣΚΓΦΥΒΣΚΠ͑΢ΦΖ͑ΣΖΕΦΔΖ͑ΝΒ͑ΡΣΚΞΒ͑ΞΖΟΤΦΒΝ͑Π͑ΡΒΣΒ͑ΦΟΒ͑ΣΖΕΦΔΔΚЃΟ͑
ΖΟ͑ΝΒ͑ΔΦΠΥΒ͑ΕΖ͑ΝΠΤ͑ΔΠΤΥΠΤ͑ΤΚ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑ΟΠ͑ΓΣΚΟΕΒ͑ΔΠΓΖΣΥΦΣΒ͑Π͑ΟΠ͑ΓΣΚΟΕΒ͑ΔΠΓΖΣΥΦΣΒ͑΢ΦΖ͑ΔΦΞΡΝΖ͑ΔΠΟ͑ΕΖΥΖΣΞΚΟΒΕΒΤ͑
ΟΠΣΞΒΤ͑͟΄Κ͑ΖΝ͑ΔΠΤΥΠ͑ΕΖΝ͑ΡΝΒΟ͑ΕΖ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑΢ΦΖ͑ΝΖ͑ΓΣΚΟΕΒΣϽΒ͑ΔΠΓΖΣΥΦΣΒ͑Β͑ΦΤΥΖΕ͙͑Ϊ͑ΟΠ͑͝Β͑ΝΠΤ͑ΕΖΞϱΤ͑ΞΚΖΞΓΣΠΤ͑ΕΖ͑
ΝΒ͑ΗΒΞΚΝΚΒ͚͑ΤΦΡΖΣΒ͑ΖΝ͖͑ͪͦ͑͑͟ΕΖΝ͑ΚΟΘΣΖΤΠ͑ΒΟΦΒΝ͑ΕΖ͑ΤΦ͑ΗΒΞΚΝΚΒ͑͝Π͑ΤΚ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑΢ΦΖ͑ΓΣΚΟΕΒ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑ΟΠ͑
ΔΦΞΡΝΖ͑ΔΠΟ͑ΝΒ͑ΟΠΣΞΒ͑ΕΖ͓͑ΧΒΝΠΣ͑ΞϽΟΚΞΠ͓͑ΖΤΥΒΓΝΖΔΚΕΒ͑ΡΠΣ͑ΝΒ͑ͽΖΪ͑ΕΖΝ͑ʹΦΚΕΒΕΠ͑ΕΖ͑΄ΒΝΦΕ͑Β͑ͳΒΛΠ͑΁ΣΖΔΚΠ͙͑ͲΗΗΠΣΕΒΓΝΖ͑
ʹΒΣΖ͑ͲΔΥ͑Π͑ͲʹͲ͑͝ΡΠΣ͑ΤΦΤ͑ΤΚΘΝΒΤ͑ΖΟ͑ΚΟΘΝϹΤ͚͑͝ΖΤ͑ΡΠΤΚΓΝΖ͑΢ΦΖ͑ΤΖΒ͑ΖΝΖΘΚΓΝΖ͑ΡΒΣΒ͑ΦΟ͑ΔΣϹΕΚΥΠ͑ΥΣΚΓΦΥΒΣΚΠ͟
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ͿΠΥΒͫ
͑΄Κ͑ΒΕ΢ΦΚΖΣΖ͑ΦΟ͑ΡΝΒΟ͑ΕΖ͑ΤΒΝΦΕ͑Β͑ΥΣΒΧϹΤ͑ΕΖΝ͑ΞΖΣΔΒΕΠ͑ΖΟ͑ΝΦΘΒΣ͑ΕΖ͑ΒΔΖΡΥΒΣ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑΢ΦΖ͑ΓΣΚΟΕΒ͑ΤΦ͑
ΖΞΡΝΖΒΕΠΣ͑͝ΖΤ͑ΡΠΤΚΓΝΖ͑΢ΦΖ͑ΡΚΖΣΕΒ͑ΝΒΤ͑ΔΠΟΥΣΚΓΦΔΚΠΟΖΤ͙͑ΤΚ͑ΝΒΤ͑ΙΒΪ͚͑΢ΦΖ͑ΖΝ͑ΖΞΡΝΖΒΕΠΣ͑ΕΒ͑ΡΒΣΒ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑΢ΦΖ͑
ΓΣΚΟΕΒ͑͟ͲΕΖΞϱΤ͑͝ΝΒΤ͑ΔΠΟΥΣΚΓΦΔΚΠΟΖΤ͑ΕΖΝ͑ΖΞΡΝΖΒΕΠΣ͙͑ΒΤϽ͑ΔΠΞΠ͑ΤΦΤ͑ΝΒΤ͑ΔΠΟΥΣΚΓΦΥΚΠΟΤ͑ΔΠΞΠ͑ΖΞΡΝΖΒΕΠ͑ΡΒΣΒ͑ΝΒ͑
ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑΢ΦΖ͑ΓΣΚΟΕΒ͑ΖΝ͑ΖΞΡΝΖΒΕΠΣ͚͑Β͑ΞΖΟΦΕΠ͑ΤΖ͑ΖΩΔΝΦΪΖΟ͑ΕΖΝ͑ΚΟΘΣΖΤΠ͑ΤΦΛΖΥΠ͑ΚΞΡΦΖΤΥΠ͑ΗΖΕΖΣΒΝ͑Ϊ͑ΖΤΥΒΥΒΝ͑͟
ͽΠΤ͑ΡΒΘΠΤ͑ΡΒΣΒ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑Β͑ΥΣΒΧϹΤ͑ΕΖΝ͑ΞΖΣΔΒΕΠ͑ΤΖ͑ΣΖΒΝΚΫΒΟ͑ΕΖΤΡΦϹΤ͑ΕΖ͑ΚΞΡΦΖΤΥΠΤ͑͑͟
¿Cómo puedo obtener más información?
΁ΒΣΒ͑ΠΓΥΖΟΖΣ͑ΞϱΤ͑ΚΟΗΠΣΞΒΔΚЃΟ͑ΤΠΓΣΖ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑΢ΦΖ͑ΓΣΚΟΕΒ͑ΖΝ͑ΖΞΡΝΖΒΕΠΣ͑͝ΔΠΟΤΦΝΥΖ͑ΖΝ͑ΣΖΤΦΞΖΟ͑ΕΖ͑ΝΒ͑ΕΖΤΔΣΚΡΔΚЃΟ͑
ΕΖΝ͑΁ΝΒΟ͑Π͑ΔΠΞΦΟϽ΢ΦΖΤΖ͑ΔΠΟ͑ΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐΐ͑͑͟
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ͶΝ͑ΞΖΣΔΒΕΠ͑ΡΦΖΕΖ͑ΒΪΦΕΒΣΝΠ͑Β͑ΖΧΒΝΦΒΣ͑ΤΦΤ͑ΠΡΔΚΠΟΖΤ͑ΕΖ͑ΔΠΓΖΣΥΦΣΒ͑͝ΚΟΔΝΦΚΕΒ͑ΤΦ͑ΖΝΖΘΚΓΚΝΚΕΒΕ͑ΡΒΣΒ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑Β͑ΥΣΒΧϹΤ͑
ΕΖΝ͑ΞΖΣΔΒΕΠ͑Ϊ͑ΤΦΤ͑ΔΠΤΥΠΤ͑͟·ΚΤΚΥΖ͑
ʹΦΚΕΒΕΠ͵Ζ΄ΒΝΦΕ͟ΘΠΧ
͑ΡΒΣΒ͑ΠΓΥΖΟΖΣ͑ΞϱΤ͑ΚΟΗΠΣΞΒΔΚЃΟ͑͝ΚΟΔΝΦΚΕΒ͑ΦΟΒ͑ΤΠΝΚΔΚΥΦΕ͑ΖΟ͑
ΝϽΟΖΒ͑ΕΖ͑ΔΠΓΖΣΥΦΣΒ͑ΕΖ͑ΤΖΘΦΣΠΤ͑ΞϹΕΚΔΠΤ͑Ζ͑ΚΟΗΠΣΞΒΔΚЃΟ͑ΕΖ͑ΔΠΟΥΒΔΥΠ͑ΡΒΣΒ͑ΦΟ͑ΞΖΣΔΒΕΠ͑ΕΖ͑ΤΖΘΦΣΠΤ͑ΞϹΕΚΔΠΤ͑ΖΟ͑ΤΦ͑
ϱΣΖΒ͑͑͟
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͢
͑ΆΟ͑ΡΝΒΟ͑ΕΖ͑ΤΒΝΦΕ͑ΡΒΥΣΠΔΚΟΒΕΠ͑ΡΠΣ͑ΖΝ͑ΖΞΡΝΖΒΕΠΣ͑ΔΦΞΡΝΖ͑ΔΠΟ͑ΝΒ͓͑ΟΠΣΞΒ͑ΕΖ͑ΧΒΝΠΣ͑ΞϽΟΚΞΠ͓͑ΤΚ͑ΝΒ͑ΡΒΣΥΚΔΚΡΒΔΚЃΟ͑ΕΖΝ͑ΡΝΒΟ͑ΖΟ͑ΝΠΤ͑ΔΠΤΥΠΤ͑ΥΠΥΒΝΖΤ͑ΕΖ͑ΓΖΟΖΗΚΔΚΠΤ͑
ΡΖΣΞΚΥΚΕΠΤ͑ΔΦΓΚΖΣΥΠΤ͑ΡΠΣ͑ΖΝ͑ΡΝΒΟ͑ΟΠ͑ΖΤ͑ΚΟΗΖΣΚΠΣ͑ΒΝ͑ͧ͑͡ΡΠΣ͑ΔΚΖΟΥΠ͑ΕΖ͑ΕΚΔΙΠΤ͑ΔΠΤΥΠΤ͑͟
Formulario aprobado
OMB N.° 1210-0149
(caduca el 31-5-2020)
Departamento de Recursos Humanos de ECC - 847-214-7988 / 847-214-7125
PARTE B: Información sobre la cobertura médica que brinda su empleador
ͶΤΥΒ͑ΤΖΔΔΚЃΟ͑ΚΟΔΝΦΪΖ͑ΚΟΗΠΣΞΒΔΚЃΟ͑ΤΠΓΣΖ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑΢ΦΖ͑ΓΣΚΟΕΒ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑͟΄Κ͑ΕΖΔΚΕΖ͑ΔΠΞΡΝΖΥΒΣ͑ΦΟΒ͑
ΤΠΝΚΔΚΥΦΕ͑ΕΖ͑ΔΠΓΖΣΥΦΣΒ͑
ΞéΕΚΔΒ
͑ΖΟ͑ΖΝ͑ΞΖΣΔΒΕΠ͑͝ΕΖΓΖΣϱ͑ΓΣΚΟΕΒΣ͑ΖΤΥΒ͑ΚΟΗΠΣΞΒΔΚЃΟ͑͟ͶΤΥΒ͑ΚΟΗΠΣΞΒΔΚЃΟ͑ΖΤΥϱ͑ΖΟΦΞΖΣΒΕΒ͑ΕΖ͑
ΗΠΣΞΒ͑ΥΒΝ͑΢ΦΖ͑ΔΠΚΟΔΚΕΒ͑ΔΠΟ͑ΝΒ͑ΤΠΝΚΔΚΥΦΕ͑ΕΖΝ͑ΞΖΣΔΒΕΠ͑͑͟
Ͳ͑ΔΠΟΥΚΟΦΒΔΚЃΟ͑͝ΖΟΔΠΟΥΣΒΣϱ͑ΚΟΗΠΣΞΒΔΚЃΟ͑ΓϱΤΚΔΒ͑ΤΠΓΣΖ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑΢ΦΖ͑ΓΣΚΟΕΒ͑ΖΤΥΖ͑ΖΞΡΝΖΒΕΠΣͫ͑͑
ח͑ʹΠΞΠ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑͝ΠΗΣΖΔΖΞΠΤ͑ΦΟ͑ΡΝΒΟ͑ΕΖ͑ΤΒΝΦΕ͑ΡΒΣΒ͑ΝΠΤ͑ΤΚΘΦΚΖΟΥΖΤͫ͑͑
΅ΠΕΠΤ͑ΝΠΤ͑ΖΞΡΝΖΒΕΠΤ͑͑͟
ͲΝΘΦΟΠΤ͑ΖΞΡΝΖΒΕΠΤ͑͟ͽΠΤ͑ΖΞΡΝΖΒΕΠΤ͑ΖΝΖΘΚΓΝΖΤ͑ΤΠΟ͑ΝΠΤ͑ΤΚΘΦΚΖΟΥΖΤͫ͑͑
ח͑ͶΟ͑ΔΦΒΟΥΠ͑Β͑ΝΠΤ͑ΕΖΡΖΟΕΚΖΟΥΖΤͫ͑͑
΄Ͻ͑ΠΗΣΖΔΖΞΠΤ͑ΔΠΓΖΣΥΦΣΒ͑
ΞéΕΚΔΒ
͑͟ͽΠΤ͑ΕΖΡΖΟΕΚΖΟΥΖΤ͑ΖΝΖΘΚΓΝΖΤ͑ΤΠΟ͑ΝΠΤ͑ΤΚΘΦΚΖΟΥΖΤͫ͑͑
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ͿΠ͑ΠΗΣΖΔΖΞΠΤ͑ΔΠΓΖΣΥΦΣΒ͑
ΞéΕΚΔΒ
͑͑͟
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΄Κ͑ΞΒΣΔΒ͑ΖΤΥΒ͑ΠΡΔΚЃΟ͑͝ΖΤΥΒ͑ΔΠΓΖΣΥΦΣΒ͑
ΞéΕΚΔΒ
͑ΔΦΞΡΝΖ͑ΔΠΟ͑ΝΒ͑ΟΠΣΞΒ͑ΕΖ͑ΧΒΝΠΣ͑ΞϽΟΚΞΠ͑͟ͲΤΚΞΚΤΞΠ͑͝ΖΝ͑ΔΠΤΥΠ͑ΕΖ͑ΝΒ͑
ΔΠΓΖΣΥΦΣΒ͑͑ΤΖ͑ΡΣΖΥΖΟΕΖ͑΢ΦΖ͑ΤΖΒ͑ΒΤΖ΢ΦΚΓΝΖ͑ΡΒΣΒ͑ΦΤΥΖΕ͑ΤΖΘЊΟ͑ΝΠΤ͑ΤΒΝΒΣΚΠΤ͑ΕΖ͑ΝΠΤ͑ΖΞΡΝΖΒΕΠΤ͑͑͟
͛͛͑ ͺΟΔΝΦΤΠ͑ΤΚ͑ΖΝ͑ΠΓΛΖΥΚΧΠ͑ΕΖ͑ΤΦ͑ΖΞΡΝΖΒΕΠΣ͑ΖΤ͑ΓΣΚΟΕΒΣΝΖ͑ΔΠΓΖΣΥΦΣΒ͑ΒΤΖ΢ΦΚΓΝΖ͑͝ΖΤ͑ΡΠΤΚΓΝΖ͑΢ΦΖ͑ΤΖΒ͑ΖΝΖΘΚΓΝΖ͑ΡΒΣΒ͑
ΠΓΥΖΟΖΣ͑ΦΟ͑ΕΖΤΔΦΖΟΥΠ͑ΖΟ͑ΝΒ͑ΡΣΚΞΒ͑Β͑ΥΣΒΧϹΤ͑ΕΖΝ͑ΞΖΣΔΒΕΠ͑͟ͶΝ͑ΞΖΣΔΒΕΠ͑ΦΥΚΝΚΫΒΣϱ͑ΖΝ͑ΚΟΘΣΖΤΠ͑ΕΖ͑ΤΦ͑ΘΣΦΡΠ͑
ΗΒΞΚΝΚΒΣ͑͝ΛΦΟΥΠ͑ΔΠΟ͑ΠΥΣΠΤ͑ΗΒΔΥΠΣΖΤ͑͝ΡΒΣΒ͑ΕΖΥΖΣΞΚΟΒΣ͑ΤΚ͑ΖΤ͑ΖΝΖΘΚΓΝΖ͑ΡΒΣΒ͑ΣΖΔΚΓΚΣ͑ΦΟ͑ΕΖΤΔΦΖΟΥΠ͑ΖΟ͑ΝΒ͑ΡΣΚΞΒ͑͟΄Κ͑͝
ΡΠΣ͑ΖΛΖΞΡΝΠ͑͝ΤΦΤ͑ΤΒΝΒΣΚΠΤ͑ΧΒΣϽΒΟ͑ΕΖ͑ΦΟΒ͑ΤΖΞΒΟΒ͑Β͑ΝΒ͑ΠΥΣΒ͙͑ΥΒΝ͑ΧΖΫ͑ΖΤ͑ΦΟ͑ΖΞΡΝΖΒΕΠ͑ΡΠΣ͑ΙΠΣΒ͑Π͑ΥΣΒΓΒΛΒ͑ΔΠΟ͑
ΔΠΞΚΤΚΠΟΖΤ͚͑͝ΤΚ͑ΗΦΖ͑ΔΠΟΥΣΒΥΒΕΠ͑ΣΖΔΚΖΟΥΖΞΖΟΥΖ͑Β͑ΞΚΥΒΕ͑ΕΖ͑ΒЁΠ͑Π͑ΤΚ͑ΥΚΖΟΖ͑ΠΥΣΒΤ͑ΡϹΣΕΚΕΒΤ͑ΕΖ͑ΚΟΘΣΖΤΠ͑͝ΒЊΟ͑ΒΤϽ͑
ΖΤ͑ΡΠΤΚΓΝΖ͑΢ΦΖ͑ΣΖЊΟΒ͑ΝΠΤ͑ΣΖ΢ΦΚΤΚΥΠΤ͑ΡΒΣΒ͑ΣΖΔΚΓΚΣ͑ΦΟ͑ΕΖΤΔΦΖΟΥΠ͑ΖΟ͑ΝΒ͑ΡΣΚΞΒ͑͑͟
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΄Κ͑ΕΖΔΚΕΖ͑ΒΕ΢ΦΚΣΚΣ͑ΔΠΓΖΣΥΦΣΒ͑Β͑ΥΣΒΧϹΤ͑ΕΖΝ͑ΞΖΣΔΒΕΠ͑͝ΧΚΤΚΥΖ͑
ʹΦΚΕΒΕΠ͵Ζ΄ΒΝΦΕ͟ΘΠΧ
͑ΡΒΣΒ͑ΠΓΥΖΟΖΣ͑ΚΟΤΥΣΦΔΔΚΠΟΖΤ͑ΤΠΓΣΖ͑
ΔЃΞΠ͑ΙΒΔΖΣΝΠ͑͟Ͳ΢ΦϽ͑ΖΟΔΠΟΥΣΒΣϱ͑ΝΒ͑ΚΟΗΠΣΞΒΔΚЃΟ͑ΕΖΝ͑ΖΞΡΝΖΒΕΠΣ͑΢ΦΖ͑ΕΖΓΖ͑ΚΟΘΣΖΤΒΣ͑ΔΦΒΟΕΠ͑ΧΚΤΚΥΒ͑
ʹΦΚΕΒΕΠ͵Ζ΄ΒΝΦΕ͟ΘΠΧ
͑
ΡΒΣΒ͑ΤΒΓΖΣ͑ΤΚ͑ΡΦΖΕΖ͑ΠΓΥΖΟΖΣ͑ΦΟ͑ΔΣϹΕΚΥΠ͑ΥΣΚΓΦΥΒΣΚΠ͑ΡΒΣΒ͑ΣΖΕΦΔΚΣ͑ΝΒΤ͑ΡΣΚΞΒΤ͑ΞΖΟΤΦΒΝΖΤ͑͑͟
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3. Nombre del empleador 4. Número de identificación del empleador (EIN,
por sus siglas en inglés)
5. Dirección del empleador 6. Número de teléfono del empleador
7. Ciudad 8. Estado 9. Código postal
10. ¿Con quién podemos comunicarnos en relación con la cobertura médica del empleado en este empleo?
11. Número de teléfono (si difiere del que figura arriba) 12. Dirección de correo electrónico
Elgin Community College District #509
36-2600170
1700 Spartan Drive
847-214-7988 / 847-214-7125
Elgin
IL
60123-7193
Recursos Humanos-Beneficios
tmenendez@elgin.edu / lgemelli@elgin.edu
Un empleado de tiempo completo que regularmente está programado a trabajar un mínimo de 35/40 horas por
semana y que está en la nómina permanente del empleador.
Cónyuge, Compañero Civil, Pareja de Hecho, Hijos
ͽΒ͑ΤΚΘΦΚΖΟΥΖ͑ΚΟΗΠΣΞΒΔΚЃΟ͑ΔΠΣΣΖΤΡΠΟΕΖ͑Β͑ΝΒ͑͹ΖΣΣΒΞΚΖΟΥΒ͑ΕΖ͑ΔΠΓΖΣΥΦΣΒ͑ΕΖΝ͑ΖΞΡΝΖΒΕΠΣ͑Β͑ΥΣΒΧϹΤ͑ΕΖΝ͑ΞΖΣΔΒΕΠ͑͟ͽΠΤ͑
ΖΞΡΝΖΒΕΠΣΖΤ͑ΟΠ͑ΥΚΖΟΖΟ͑ΝΒ͑ΠΓΝΚΘΒΔΚЃΟ͑ΕΖ͑ΔΠΞΡΝΖΥΒΣ͑ΖΤΥΒ͑ΤΖΔΔΚЃΟ͑͝ΡΖΣΠ͑ΙΒΔΖΣΝΠ͑ΒΪΦΕΒΣϱ͑Β͑ΘΒΣΒΟΥΚΫΒΣ͑΢ΦΖ͑ΝΠΤ͑
ΖΞΡΝΖΒΕΠΤ͑ΖΟΥΚΖΟΕΖΟ͑ΤΦΤ͑ΠΡΔΚΠΟΖΤ͑ΕΖ͑ΔΠΓΖΣΥΦΣΒ͑͟
13. Actualmente, ¿el empleado es elegible para la cobertura que brinda el empleador o lo será
en los próximos 3 meses?
΄Ͻ
͙͑͟ʹΠΟΥΚΟЊΖ͚͑͑͟
ͤ͢Β͑͟΄Κ͑ΖΝ͑ΖΞΡΝΖΒΕΠ͑ΟΠ͑ΖΤ͑ΖΝΖΘΚΓΝΖ͑ΒΔΥΦΒΝΞΖΟΥΖ͑͝ΚΟΔΝΦΤΠ͑ΔΠΞΠ͑ΣΖΤΦΝΥΒΕΠ͑ΕΖ͑ΦΟ͑ΡΖΣϽΠΕΠ͑ΕΖ͑ΖΤΡΖΣΒ͑Π͑ΕΖ͑ΡΣΦΖΓΒ͑͝ϏΔΦϱΟΕΠ͑
ΤΖΣϱ͑ΖΝΖΘΚΓΝΖ͑ΡΒΣΒ͑ΝΒ͑ΔΠΓΖΣΥΦΣΒͰ͙͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑ΕΕ͠ΞΞ͠ΒΒΒΒ͚͙͑͟ʹΠΟΥΚΟЊΖ͚͑͑͟
ͿΠ
͙͑͟͵Ͷ΅ϙͿ͸Ͳ΄Ͷ͑Ϊ͑ΕΖΧΦΖΝΧΒ͑ΖΤΥΖ͑ΗΠΣΞΦΝΒΣΚΠ͑ΒΝ͑ΖΞΡΝΖΒΕΠ͚͑͑͟
14. ¿El empleador brinda un plan de salud que cumple con la norma de valor mínimo*?
Sí. (Pase a la pregunta 15). No. (DETÉNGASE y devuelva el formulario al empleado).
15.
Para
el plan de menor costo que cumple con la norma de valor mínimo* ofrecido únicamente al empleado (no incluya los planes familiares):
Si el empleador dispone de programas de bienestar, incluya la prima que el empleado pagaría si recibiera el descuento máximo para los programas
para dejar de fumar y no recibiera ningún otro descuento sobre la base de los programas de bienestar.
a. ¿
Cuánto tendría que pagar el empleado en lo que respecta a las primas para este plan? $
b. ¿Con qué frecuencia? Semanalmente Cada 2 semanas Dos veces al mes Mensualmente Trimestralmente
Anualmente
΄Κ͑ΖΝ͑ΒЁΠ͑ΕΖΝ͑ΡΝΒΟ͑ΖΤΥϱ͑ΡΠΣ͑ΗΚΟΒΝΚΫΒΣ͑Ϊ͑ΦΤΥΖΕ͑ΤΒΓΖ͑΢ΦΖ͑ΝΠΤ͑ΡΝΒΟΖΤ͑ΕΖ͑ΤΒΝΦΕ͑ΠΗΣΖΔΚΕΠΤ͑ΤΦΗΣΚΣϱΟ͑ΦΟΒ͑ΞΠΕΚΗΚΔΒΔΚЃΟ͑͝ΡΒΤΖ͑
Β͑ΝΒ͑ΡΣΖΘΦΟΥΒ͑ͧ͑͢͟΄Κ͑ΟΠ͑ΝΠ͑ΤΒΓΖ͑͝͵Ͷ΅ϙͿ͸Ͳ΄Ͷ͑Ϊ͑ΕΖΧΦΖΝΧΒ͑ΖΝ͑ΗΠΣΞΦΝΒΣΚΠ͑ΒΝ͑ΖΞΡΝΖΒΕΠ͑͑͟
ͧ͑͢͟Ϗ΂ΦϹ͑ΞΠΕΚΗΚΔΒΔΚЃΟ͑ΙΒΣϱ͑ΖΝ͑ΖΞΡΝΖΒΕΠΣ͑ΡΒΣΒ͑ΖΝ͑ΟΦΖΧΠ͑ΒЁΠ͑ΕΖΝ͑ΡΝΒΟͰ͑͑
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ͶΝ͑ΖΞΡΝΖΒΕΠΣ͑ΔΠΞΖΟΫΒΣϱ͑Β͑ΓΣΚΟΕΒΣ͑ΔΠΓΖΣΥΦΣΒ͑ΞϹΕΚΔΒ͑Β͑ΝΠΤ͑ΖΞΡΝΖΒΕΠΤ͑Π͑ΞΠΕΚΗΚΔΒΣϱ͑ΝΒ͑ΡΣΚΞΒ͑ΡΒΣΒ͑ΖΝ͑ΡΝΒΟ͑ΕΖ͑
ΞΖΟΠΣ͑ΔΠΤΥΠ͑ΕΚΤΡΠΟΚΓΝΖ͑ЊΟΚΔΒΞΖΟΥΖ͑ΡΒΣΒ͑ΖΝ͑ΖΞΡΝΖΒΕΠ͑͝΢ΦΖ͑ΔΦΞΡΝΖ͑ΔΠΟ͑ΝΒ͑ΟΠΣΞΒ͑ΕΖ͑ΧΒΝΠΣ͑ΞϽΟΚΞΠ͙͛͑͟ͽΒ͑
ΡΣΚΞΒ͑ΕΖΓΖ͑ΣΖΗΝΖΛΒΣ͑ΖΝ͑ΕΖΤΔΦΖΟΥΠ͑ΡΒΣΒ͑ΝΠΤ͑ΡΣΠΘΣΒΞΒΤ͑ΕΖ͑ΓΚΖΟΖΤΥΒΣ͑͟·ΖΒ͑ΝΒ͑ΡΣΖΘΦΟΥΒ͚͑ͦ͑͑͢͟
͑
Β͑͟ϏʹΦϱΟΥΠ͑ΥΖΟΕΣϱ͑΢ΦΖ͑ΡΒΘΒΣ͑ΖΝ͑ΖΞΡΝΖΒΕΠ͑ΖΟ͑ΝΠ͑΢ΦΖ͑ΣΖΤΡΖΔΥΒ͑Β͑ΝΒΤ͑ΡΣΚΞΒΤ͑ΡΒΣΒ͑ΕΚΔΙΠ͑ΡΝΒΟͰ͕͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑
͑
Γ͑͟ϏʹΠΟ͑΢ΦϹ͑ΗΣΖΔΦΖΟΔΚΒͰ͑ ͑ ΄ΖΞΒΟΒΝΞΖΟΥΖ͑͑ ʹΒΕΒ͑ͣ͑ΤΖΞΒΟΒΤ͑ ͵ΠΤ͑ΧΖΔΖΤ͑ΒΝ͑ΞΖΤ͑
͑͑͑͑;ΖΟΤΦΒΝΞΖΟΥΖ͑͑΅ΣΚΞΖΤΥΣΒΝΞΖΟΥΖ͑͑ͲΟΦΒΝΞΖΟΥΖ͑͑
͑
ͷΖΔΙΒ͑ΕΖ͑ΝΒ͑ΞΠΕΚΗΚΔΒΔΚЃΟ͙͑ΕΕ͠ΞΞ͠ΒΒΒΒ͚ͫ͑͑
͑
͑
͑
͑
͑
͑
͑
͑
͑
͑
͑
͑
͑
͑
͑
͑
ח͑ΆΟ͑ΡΝΒΟ͑ΕΖ͑ΤΒΝΦΕ͑ΡΒΥΣΠΔΚΟΒΕΠ͑ΡΠΣ͑ΖΝ͑ΖΞΡΝΖΒΕΠΣ͑ΔΦΞΡΝΖ͑ΔΠΟ͑ΝΒ͓͑ΟΠΣΞΒ͑ΕΖ͑ΧΒΝΠΣ͑ΞϽΟΚΞΠ͓͑ΤΚ͑ΝΒ͑ΡΒΣΥΚΔΚΡΒΔΚЃΟ͑ΕΖΝ͑ΡΝΒΟ͑ΖΟ͑ΝΠΤ͑ΔΠΤΥΠΤ͑
ΥΠΥΒΝΖΤ͑ΕΖ͑ΓΖΟΖΗΚΔΚΠΤ͑ΡΖΣΞΚΥΚΕΠΤ͑ΔΦΓΚΖΣΥΠΤ͑ΡΠΣ͑ΖΝ͑ΡΝΒΟ͑ΟΠ͑ΖΤ͑ΚΟΗΖΣΚΠΣ͑ΒΝ͑ͧ͑͡ΡΠΣ͑ΔΚΖΟΥΠ͑ΕΖ͑ΕΚΔΙΠΤ͑ΔΠΤΥΠΤ͙͑ͲΣΥϽΔΦΝΠ͑ͤͧͳ͙Δ͚͙͚͙ͣʹ͚͙ΚΚ͚͑ΕΖΝ͑
ʹЃΕΚΘΠ͑΅ΣΚΓΦΥΒΣΚΠ͑ΕΖ͚͑ͪͩͧ͢͟
͑
Human Resources - Benefits
CMSForm10182CCUpdated04/01/2011
TO: All Employees Eligible for Medicare Part D and Currently Participating in the ECC Group Health Plan
FROM: Employee Benefits Department
RE: Annual Notice – Medicare Part D – Creditable Coverage
Important Notice from Elgin Community College 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 Elgin Community College’s group health plan 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 monthly premium.
2. Elgin Community College has determined that the prescription drug coverage offered by the Blue
Cross Blue Shield of Illinois group health plan (including both the HMO and PPO plans) 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
15
th
through December 7
th
.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will
also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Elgin Community College coverage will not be affected.
Your current Elgin Community College coverage pays for other health expenses in addition to prescription
drugs. If you enroll in a Medicare prescription plan, you and your eligible dependents may still be eligible to
receive all your current health and prescription drug benefits.
CMSForm10182CCUpdated04/01/2011
If you do decide to join a Medicare drug plan and drop your current Elgin Community College coverage, be
aware that you and your dependents will be able to get this coverage back, subject to the plan’s enrollment
rights.
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 Elgin Community College and don’t
join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher
premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium
may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did
not have that coverage. For example, if you go 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 contact the Benefits Office of Human Resources at (847) 214-7988 or (847) 214-7125.
NOTE: You’ll get this notice each year before the next period you can join a Medicare drug plan and if this
coverage through Elgin Community College changes. You also may request a copy of this notice at any time
and it will be available on e-NET.
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 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.
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 1-800-772-1213 (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: September 5, 2019
Name of Entity/Sender: Elgin Community College
Contact--Position/Office: Employee Benefits Office
Address: 1700 Spartan Drive, Elgin, IL 60123-1793
Phone Number: (847) 214-7988 or (847) 214-7125
Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and youre 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 arent 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 arent 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, 2019. Contact your State for more
information on eligibility
ALABAMA Medicaid
FLORIDA Medicaid
Website: http://myalhipp.com/
Phone: 1-855-692-5447
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-877-357-3268
ALASKA Medicaid
GEORGIA Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility:
http://dhss.alaska.gov/dpa/Pages/medicaid/default.asp
x
Website: https://medicaid.georgia.gov/health-
insurance-premium-payment-program-hipp
Phone: 678-564-1162 ext 2131
ARKANSAS Medicaid
INDIANA Medicaid
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/
Phone: 1-877-438-4479
All other Medicaid
Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
COLORADO Health First Colorado
(Colorado’s Medicaid Program) & Child
Health Plan Plus (CHP+)
IOWA Medicaid
Health First Colorado Website:
https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center:
1-800-221-3943/ State Relay 711
CHP+:
https://www.colorado.gov/pacific/hcpf/child-health-
plan-plus
CHP+ Customer Service: 1-800-359-1991/ State Relay 711
Website:
http://dhs.iowa.gov/Hawki
Phone: 1-800-257-8563
KANSAS Medicaid
NEW HAMPSHIRE Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-785-296-3512
Website: https://www.dhhs.nh.gov/oii/hipp.htm
Phone: 603-271-5218
Toll free number for the HIPP program: 1-800-852-
3345, ext 5218
KENTUCKY Medicaid
NEW JERSEY Medicaid and CHIP
Website: https://chfs.ky.gov
Phone: 1-800-635-2570
Medicaid Website:
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
Phone: 1-888-695-2447
Website:
https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-541-2831
MAINE Medicaid
NORTH CAROLINA Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-
assistance/index.html
Phone: 1-800-442-6003
TTY: Maine relay 711
Website: https://medicaid.ncdhhs.gov/
Phone: 919-855-4100
MASSACHUSETTS Medicaid and CHIP
NORTH DAKOTA Medicaid
Website:
http://www.mass.gov/eohhs/gov/departments/masshe
alth/
Phone: 1-800-862-4840
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid
/
Phone: 1-844-854-4825
MINNESOTA Medicaid
OKLAHOMA Medicaid and CHIP
Website:
https://mn.gov/dhs/people-we-serve/seniors/health-
care/health-care-programs/programs-and-
services/other-insurance.jsp
Phone: 1-800-657-3739
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
MISSOURI Medicaid
OREGON Medicaid
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.
htm
Phone: 573-751-2005
Website:
http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
MONTANA Medicaid
PENNSYLVANIA Medicaid
Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/HI
PP
Phone: 1-800-694-3084
Website:
http://www.dhs.pa.gov/provider/medicalassistance/he
althinsurancepremiumpaymenthippprogram/index.ht
m
Phone: 1-800-692-7462
NEBRASKA Medicaid
RHODE ISLAND Medicaid and CHIP
Website: http://www.ACCESSNebraska.ne.gov
Phone: (855) 632-7633
Lincoln: (402) 473-7000
Omaha: (402) 595-1178
Website: http://www.eohhs.ri.gov/
Phone: 855-697-4347, or 401-462-0311 (Direct RIte Share
Line)
NEVADA Medicaid
SOUTH CAROLINA Medicaid
Medicaid Website: https://dhcfp.nv.gov
Medicaid Phone: 1-800-992-0900
Website: https://www.scdhhs.gov
Phone: 1-888-549-0820
To see if any other states have added a premium assistance program since July 31, 2019, or for more information
on special enrollment rights, contact either:
U.
S. Department of Labor U.S. D
epartment of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.d
ol.gov/agencies/ebsa www.cms.hhs.gov
1-86
6-444-EBSA (3272)
1-877-267-2323, 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 ebsa.opr@dol.gov
and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 12/31/2019)
SOUTH DAKOTA - Medicaid
WASHINGTON Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website: https://www.hca.wa.gov/
Phone: 1-800-562-3022 ext. 15473
TEXAS Medicaid
WEST VIRGINIA Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
Website: http://mywvhipp.com/
Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
UTAH Medicaid and CHIP
WISCONSIN Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
Website:
https://www.dhs.wisconsin.gov/publications/p1/p10095.p
df
Phone: 1-800-362-3002
VERMONTMedicaid
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
09/2017
TO: All Employees Eligible for the ECC Group Health Plan
FROM: Employee Benefits Department
RE: Annual Notice – Notice of Privacy
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT COVERED PERSONS MAY BE
USED AND DISCLOSED AND HOW COVERED PERSONS CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (“Notice”) describes how protected health information may be used or
disclosed by this Plan to carry out treatment, payment, health care operations and for other purposes
that are permitted or required by law. This Notice also sets out this Plan’s legal obligations concerning a
Covered Person’s protected health information and describes a Covered Person’s rights to access and
control that protected health information.
Protected health information (“PHI”) is individually identifiable health information, including demographic
information, collected from a Covered Person or created or received by a health care provider, a health
plan, an employer (when functioning on behalf of the group health plan), or a health care clearinghouse
and that relates to: (1) a Covered Person’s past, present or future physical or mental health or
condition; (2) the provision of health care to a Covered Person; or (3) the past, present or future
payment for the provision of health care to a Covered Person.
This Notice has been drafted to be consistent with what is known as the “HIPAA Privacy Rule,” and any
of the terms not defined in this Notice should have the same meaning as they have in the HIPAA
Privacy Rule.
If you have any questions or want additional information about the Notice or the policies and
procedures described in the Notice, please contact your Group Health Plan Privacy Officer or Human
Resources office.
THE PLAN’S RESPONSIBILITIES
The Plan is required by law to maintain the privacy of a Covered Person’s PHI. The Plan is obligated to
provide you with a copy of this Notice of the Plan’s legal duties and of its privacy practices with respect
to PHI, and the Plan must abide by the terms of this Notice. The Plan reserves the right to change the
provisions of this Notice and make the new provisions effective for all PHI that is maintained. If the Plan
makes a material change to this Notice, a revised Notice will be mailed to the address that the Plan has
on record.
When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make
reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to
accomplish the intended purpose of the use, disclosure or request, taking into consideration practical
and technological limitations.
However, the minimum necessary standard will not apply in the following situations:
disclosures to or requests by a health care provider for treatment;
uses or disclosures made to the individual;
disclosures made to the Secretary of the U.S. Department of Health and Human Services;
uses or disclosures that are required by law;
uses or disclosures that are required for compliance with the HIPAA Privacy Rule; and
uses or disclosures made pursuant to an authorization.
*This Notice does not apply to information that has been de-identified. De-identified information is
health information that does not identify an individual and with respect to which there is no reasonable
basis to believe that the information can be used to identify an individual. It is not individually
identifiable health information.
Primary Uses and Disclosures of Protected Health Information
The following is a description of how the Plan is most likely to use/disclose a Covered Person’s PHI.
Treatment, Payment and Health Care Operations
The Plan has the right to use and disclose a Covered Person’s PHI for all activities that are
included within the definitions of “treatment, payment and health care operations” as
described in the HIPAA Privacy Rule.
Treatment
The Plan will use or disclose PHI so that a Covered Person may seek treatment.
Treatment is the provision, coordination or management of health care and related
services. It also includes, but is not limited to consultations and referrals between one or
more of a Covered Person’s providers. For example, the Plan may disclose to a treating
specialist the name of a Covered Person’s primary care physician so that the specialist
may request medical records from that primary care physician.
Payment
The Plan will use or disclose PHI to pay claims for services provided to a Covered
Person and to obtain stop loss reimbursements, if applicable, or to otherwise fulfill the
Plan’s responsibilities for coverage and providing benefits. For example, the Plan may
disclose PHI when a provider requests information regarding a Covered Person’s
eligibility for coverage under this Plan, or the Plan may use PHI to determine if a
treatment that was received was medically necessary.
Health Care Operations
The Plan will use or disclose PHI to support its business functions. These functions
include, but are not limited to quality assessment and improvement, reviewing provider
performance, licensing, stop loss underwriting, business planning and business
development. For example, the Plan may use or disclose PHI: (1) to provide a Covered
Person with information about a disease management program; (2) to respond to a
customer service inquiry from a Covered Person or (3) in connection with fraud and
abuse detection and compliance programs.
Business Associates
The Plan contracts with individuals and entities (Business Associates) to perform various
functions on its behalf or to provide certain types of services. To perform these functions or to
provide the services, the Plan’s Business Associates will receive, create, maintain, use or
disclose PHI, but only after the Plan requires the Business Associates to agree in writing to
contract terms designed to appropriately safeguard PHI. For example, the Plan may disclose
PHI to a Business Associate to administer claims or to provide service support, utilization
management, subrogation or pharmacy benefit management. Examples of the Plan’s
Business Associates would be its third party administrator, broker, preferred provider
organization and utilization review vendor.
Other Covered Entities
The Plan may use or disclose PHI to assist health care providers in connection with their
treatment or payment activities or to assist other covered entities in connection with
payment activities and certain health care operations. For example, the Plan may disclose
PHI to a health care provider when needed by the provider to render treatment to a Covered
Person, and the Plan may disclose PHI to another covered entity to conduct health care
operations in the areas of fraud and abuse detection or compliance, quality assurance and
improvement activities or accreditation, certification, licensing or credentialing. This also
means that the Plan may disclose or share PHI with other insurance carriers in order to
coordinate benefits, if a Covered Person has coverage through another carrier.
Plan Sponsor
The Plan may disclose PHI to the Plan Sponsor of the group health plan for purposes of
plan administration or pursuant to an authorization request signed by the Covered Person.
Also, the Plan may use or disclose “summary health information” to the Plan Sponsor for
obtaining premium bids or modifying, amending or terminating the group health plan.
Summary health information summarizes the claims history, claims expenses or types of
claims experienced by individuals for whom a Plan Sponsor has provided health benefits
under a group health plan and from which identifying information has been deleted in
accordance with the HIPAA Privacy Rule.
Potential Impact of State Law
The HIPAA Privacy Regulations generally do not “preempt” (or take precedence over) state
privacy or other applicable laws that provide individuals greater privacy protections. As a result,
to the extent state law applies, the privacy laws of a particular state, or other federal laws,
rather than the HIPAA Privacy Regulations, might impose a privacy standard under which the
Plan will be required to operate. For example, where such laws have been enacted, the Plan will
follow more stringent state privacy laws that relate to uses and disclosures of PHI concerning
HIV or AIDS, mental health, substance abuse/chemical dependency, genetic testing,
reproductive rights, etc.
Other Possible Uses and Disclosures of PHI
The following is a description of other possible ways in which the Plan may (and is permitted to)
use and/or disclose PHI.
Required by Law
The Plan may use or disclose PHI to the extent that federal law requires the use or
disclosure. When used in this Notice, “required by law” is defined as it is in the HIPAA
Privacy Rule. For example, the Plan may disclose PHI when required by national security
laws or public health disclosure laws.
Public Health Activities
The Plan may use or disclose PHI for public health activities that are permitted or required
by law. For example, the Plan may use or disclose information for the purpose of preventing
or controlling disease, injury, or disability, or it may disclose such information to a public
health authority authorized to receive reports of child abuse or neglect. The Plan also may
disclose PHI, if directed by a public health authority, to a foreign government agency that is
collaborating with the public health authority.
Health Oversight Activities
The Plan may disclose PHI to a health oversight agency for activities authorized by law, such
as: audits; investigations; inspections; licensure or disciplinary actions; or civil,
administrative, or criminal proceedings or actions. Oversight agencies seeking this
information include government agencies that oversee: (1) the health care system; (2)
government benefit programs; (3) other government regulatory programs and (4) compliance
with civil rights laws.
Abuse or Neglect
The Plan may disclose PHI to a government authority that is authorized by law to receive
reports of abuse, neglect or domestic violence. Additionally, as required by law, the Plan
may disclose to a governmental entity, authorized to receive such information, a Covered
Person’s PHI if there is reason to believe that the Covered Person has been a victim of
abuse, neglect, or domestic violence.
Legal Proceedings
The Plan may disclose PHI: (1) in the course of any judicial or administrative proceeding; (2)
in response to an order of a court or administrative tribunal (to the extent such disclosure is
expressly authorized) and (3) in response to a subpoena, a discovery request, or other lawful
process, once the Plan has met all administrative requirements of the HIPAA Privacy Rule.
For example, the Plan may disclose PHI in response to a subpoena for such information, but
only after first meeting certain conditions required by the HIPAA Privacy Rule.
Law Enforcement
Under certain conditions, the Plan also may disclose PHI to law enforcement officials. For
example, some of the reasons for such a disclosure may include, but not be limited to: (1) it
is required by law or some other legal process; (2) it is necessary to locate or identify a
suspect, fugitive, material witness, or missing person or (3) it is necessary to provide
evidence of a crime.
Coroners, Medical Examiners, Funeral Directors, and Organ Donation
The Plan may disclose PHI to a coroner or medical examiner for purposes of identifying a
deceased person, determining a cause of death or for the coroner or medical examiner to
perform other duties authorized by law. The Plan also may disclose, as authorized by law,
information to funeral directors so that they may carry out their duties. Further, the Plan may
disclose PHI to organizations that handle organ, eye or tissue donation and transplantation.
Research
The Plan may disclose PHI to researchers when an institutional review board or privacy
board has: (1) reviewed the research proposal and established protocols to ensure the
privacy of the information and (2) approved the research.
To Prevent a Serious Threat to Health or Safety
Consistent with applicable federal and state laws, the Plan may disclose PHI if there is reason
to believe that the disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public. The Plan also may disclose PHI if it is
necessary for law enforcement authorities to identify or apprehend an individual.
Military Activity and National Security, Protective Services
Under certain conditions, the Plan may disclose PHI if Covered Persons are, or were, Armed
Forces personnel for activities deemed necessary by appropriate military command
authorities. If Covered Persons are members of foreign military service, the Plan may
disclose, in certain circumstances, PHI to the foreign military authority. The Plan also may
disclose PHI to authorized federal officials for conducting national security and intelligence
activities, and for the protection of the President, other authorized persons or heads of
state.
Inmates
If a Covered Person is an inmate of a correctional institution, the Plan may disclose PHI to
the correctional institution or to a law enforcement official for: (1) the institution to provide
health care to the Covered Person; (2) the Covered Person’s health and safety and the health
and safety of others or (3) the safety and security of the correctional institution.
Workers' Compensation
The Plan may disclose PHI to comply with workers' compensation laws and other similar
programs that provide benefits for work-related injuries or illnesses.
Others Involved in Your Health Care
Using its best judgment, the Plan may make PHI known to a family member, other relative,
close personal friend or other personal representative that the Covered Person identifies.
Such use will be based on how involved the person is in the Covered Person’s care or in the
payment that relates to that care. The Plan may release information to parents or guardians, if
allowed by law.
The Plan also may disclose PHI to an entity assisting in a disaster relief effort so that a
Covered Person’s family can be notified about his/her condition, status, and location. If a
Covered Person is not present or able to agree to these disclosures of PHI, then, using its
professional judgment, the Plan may determine whether the disclosure is in the Covered
Person’s best interest.
Required Disclosures of PHI
The following is a description of disclosures that the Plan is required by law to make.
Disclosures to the Secretary of the U.S. Department of Health and Human Services The Plan
is required to disclose PHI to the Secretary of the U.S. Department of Health and Human
Services when the Secretary is investigating or determining the Plan’s compliance with the
HIPAA Privacy Rule.
Disclosures to Covered Persons
The Plan is required to disclose to a Covered Person most of the PHI in a “designated record
set” when that Covered Person requests access to this information. Generally, a designated
record set contains medical and billing records, as well as other records that are used to
make decisions about a Covered Person’s health care benefits. The Plan also is required to
provide, upon the Covered Person’s request, an accounting of most disclosures of his/her
PHI that are for reasons other than treatment, payment and health care operations and are
not disclosed through a signed authorization.
The Plan will disclose a Covered Person’s PHI to an individual who has been designated by
that Covered Person as his/her personal representative and who has qualified for such
designation in accordance with relevant state law. However, before the Plan will disclose PHI
to such a person, the Covered Person must submit a written notice of his/her designation,
along with the documentation that supports his/her qualification (such as a power of
attorney).
Even if the Covered Person designates a personal representative, the HIPAA Privacy Rule
permits the Plan to elect not to treat that individual as the Covered Person’s personal
representative if a reasonable belief exists that: (1) the Covered Person has been, or may be,
subjected to domestic violence, abuse or neglect by such person; (2) treating such person as
his/her personal representative could endanger the Covered Person, or (3) the Plan
determines, in the exercise of its professional judgment, that it is not in its best interest to
treat that individual as the Covered Person’s personal representative.
Other Uses and Disclosures of PHI
Other uses and disclosures of PHI that are not described previously will be made only with a
Covered Person’s written authorization. If the Covered Person provides the Plan with such
an authorization, he/she may revoke the authorization in writing, and this revocation will be
effective for future uses and disclosures of PHI. However, the revocation will not be effective
for information that has already been used or disclosed, relying on the authorization.
A COVERED PERSON’S RIGHTS
The following is a description of a Covered Person’s rights with respect to PHI:
Right to Request a Restriction
A Covered Person has the right to request a restriction on the PHI the Plan uses or
discloses about him/her for treatment, payment or health care operations. The plan is not
required to agree to any restriction that a Covered Person may request. If the Plan does
agree to the restriction, it will comply with the restriction unless the information is needed to
provide emergency treatment.
A Covered Person may request a restriction by contacting the individual or office referenced
in the beginning of this Notice. It is important that the Covered Person directs his/her
request for restriction to this individual or office so that the Plan can begin to process your
request. Requests sent to individuals or offices other than the one indicated might delay
processing the request.
The Plan will want to receive this information in writing and will instruct the Covered Person
where to send the request when the Covered Person’s call is received. In this request, it is
important that the Covered Person states: (1) the information whose disclosure he/she
wants to limit and (2) how he/she wants to limit the Plan’s use and/or disclosure of the
information.
Right to Request Confidential Communications
If a Covered Person believes that a disclosure of all or part of his/her PHI may endanger
him/her that Covered Person may request that the Plan communicates with him/her
regarding PHI in an alternative manner or at an alternative location. For example, the
Covered Person may ask that the Plan only contact the Covered Person at a work address or
via the Covered Person’s work e-mail.
The Covered Person may request a restriction by contacting the individual or office
referenced in the beginning of this Notice. It is important that the request for confidential
communications is addressed to this individual or office so that the Plan can begin to
process the request. Requests sent to individuals or offices other than the one indicated
might delay processing the request.
The Plan will want to receive this information in writing and will instruct the Covered Person
where to send a written request upon receiving a call. This written request should inform the
Plan: (1) that he/she wants the Plan to communicate his/her PHI in an alternative manner or
at an alternative location and (2) that the disclosure of all or part of this PHI in a manner
inconsistent with these instructions would put the Covered Person in danger.
The Plan will accommodate a request for confidential communications that is reasonable
and that states that the disclosure of all or part of a Covered Person’s PHI could endanger
that Covered Person. As permitted by the HIPAA Privacy Rule, “reasonableness” will (and is
permitted to) include, when appropriate, making alternate arrangements regarding payment.
Accordingly, as a condition of granting a Covered Person’s request, he/she will be required to
provide the Plan information concerning how payment will be handled. For example, if the
Covered Person submits a claim for payment, state or federal law (or the Plan’s own
contractual obligations) may require that the Plan disclose certain financial claim information
to the Plan Participant under whose coverage a Covered Person may receive benefits (e.g.,
an Explanation of Benefits “EOB”). Unless the Covered Person has made other payment
arrangements, the EOB (in which a Covered Person’s PHI might be included) will be released
to the Plan Participant.
Once the Plan receives all the information for such a request (along with the instructions for
handling future communications), the request will be processed usually within two business
days or as soon as reasonably possible.
Prior to receiving the information necessary for this request or during the time it takes to
process it, PHI may be disclosed (such as through an EOB). Therefore, it is extremely
important that the Covered Person contact the Plan at the number listed in this Notice as
soon as the Covered Person determines the need to restrict disclosures of his/her PHI.
If the Covered Person terminates his/her request for confidential communications, the
restriction will be removed for all of the Covered Person’s PHI that the Plan holds, including
PHI that was previously protected. Therefore, a Covered Person should not terminate a
request for confidential communications if that person remains concerned that disclosure of
PHI will endanger him/her.
Right to Inspect and Copy
A Covered Person has the right to inspect and copy PHI that is contained in a “designated
record set.” Generally, a designated record set contains medical and billing records, as well
as other records that are used to make decisions about a Covered Person’s health care
benefits. However, the Covered Person may not inspect or copy psychotherapy notes or
certain other information that may be contained in a designated record set.
To inspect and copy PHI that is contained in a designated record set, the Covered Person
must submit a request by contacting the individual or office referenced in the beginning of
this Notice. It is important that the Covered Person contact this individual or office to
request an inspection and copying so that the Plan can begin to process the request.
Requests sent to individuals or offices other than the one indicated might delay the
processing of the request. If the Covered Person requests a copy of the information, the Plan
may charge a fee for the costs of copying, mailing or other supplies associated with that
request.
The Plan may deny a Covered Person’s request to inspect and copy PHI in certain limited
circumstances. If a Covered Person is denied access to information, he/she may request that
the denial be reviewed. To request a review, the Covered Person must contact the individual
or office referenced in the beginning of this Notice. A licensed health care professional
chosen by the Plan will review the Covered Person’s request and the denial. The person
performing this review will not be the same one who denied the Covered Person’s initial
request. Under certain conditions, the Plan’s denial will not be reviewable. If this event
occurs, the Plan will inform the Covered Person through the denial that the decision is not
reviewable.
Right to Amend
If a Covered Person believes that his/her PHI is incorrect or incomplete, he/she may request
that the Plan amend that information. The Covered Person may request that the Plan amend
such information by contacting the individual or office referenced in the beginning of this
Notice. Additionally, this request should include the reason the amendment is necessary. It
is important that the Covered Person direct this request for amendment to this individual or
office so that the Plan can begin to process the request. Requests sent to individuals or
offices other than the one indicated might delay processing the request.
In certain cases, the Plan may deny the Covered Person’s request for an amendment. For
example, the Plan may deny the request if the information the Covered Person wants to
amend is not maintained by the Plan, but by another entity. If the Plan denies the request,
the Covered Person has the right to file a statement of disagreement with the Plan. This
statement of disagreement will be linked with the disputed information and all future
disclosures of the disputed information will include this statement.
Right of an Accounting
The Covered Person has a right to an accounting of certain disclosures of PHI that are for
reasons other than treatment, payment or health care operations. No accounting of
disclosures is required for disclosures made pursuant to a signed authorization by the
Covered Person or his/her personal representative. The Covered Person should know that
most disclosures of PHI will be for purposes of payment or health care operations, and,
therefore, will not be subject to this right. There also are other exceptions to this right.
An accounting will include the date(s) of the disclosure, to whom the Plan made the
disclosure, a brief description of the information disclosed and the purpose for the
disclosure.
A Covered Person may request an accounting by submitting a request in writing to the
individual or office referenced in the beginning of this Notice. It is important that the
Covered Person direct the request for an accounting to this individual or office so that the
Plan can begin to process the request. Requests sent to individuals or offices other than the
one indicated might delay processing the request.
A Covered Person’s request may be for disclosures made up to 6 years before the date of the
request, but not for disclosures made before April 14, 2004. The first list requested within a
12~month period will be free. For additional lists, the Plan may charge for the costs of
providing the list. The Plan will notify the Covered Person of the cost involved and he/she
may choose to withdraw or modify the request before any costs are incurred.
Right to a Paper Copy of This Notice
The Covered Person has the right to a paper copy of this Notice, even if he/she has agreed to
accept this Notice electronically.
COMPLAINTS
A Covered Person may complain to the Plan if he/she believes that the Plan has violated these
privacy rights. The Covered Person may file a complaint with the Plan by contacting the
individual or office referenced in the beginning of this Notice. A copy of a complaint form is
available from this contact office.
A Covered Person also may file a complaint with the Secretary of the U.S. Department of Health
and Human Services. Complaints filed directly with the Secretary must: (1) be in writing; (2)
contain the name of the entity against which the complaint is lodged; (3) describe the relevant
problems and (4) be filed within 180 days of the time the Covered Person became or should
have become aware of the problem.
The Plan will not penalize or in any other way retaliate against a Covered Person for filing
a complaint with the Secretary or with the Plan.
TO: All Employees Eligible for the ECC Group Health Plan
FROM: Employee Benefits Department
RE: Annual Notice HB5285 Military Veterans
SEMI-ANNUAL NOTICE REGARDING HEALTH INSURANCE COVERAGE
FOR DEPENDENTS
Illinois law requires your Health Plan to allow unmarried dependents the right to elect or
continue coverage until the dependent reaches the age of 26 (and until the age of 30 for military
veteran dependents).
Enrollment Period: Aside from your initial eligibility to participate in your Plan, you may make a
written election for coverage of any unmarried dependent not currently covered under the Plan
during the Plan’s next annual open enrollment period for dependent coverage, or if the Plan has
no open enrollment period, enrollment during the 30 day period prior to the Plan’s annual
renewal date. The effective date of coverage for each newly enrolled dependent will be
governed by the terms of your Plan’s summary plan description.
Military Veterans: In connection with military veteran dependents, such dependents must 1)
reside in Illinois, 2) not be married, 3) have served in the active or reserve components of the
United States Armed Forces, including the National Guard, 4) have received a release or
discharge other than a dishonorable discharge, and 5) have submitted a proof of service using a
DD2-14 (Member 4 or 6) form, otherwise known as a “Certificate of Release or Discharge from
Active Duty.” This form is issued by the federal government to all veterans. For more
information as to how to obtain a copy of the DD2-14, the veteran can call the Illinois
Department of Veterans’ Affairs at 1-800-437-9824 or the United States Department of
Veterans’ Affairs at 1-800-827-1000.
Cost: You may be required to pay all or part of the cost of this extended dependent coverage,
which may be taxable. For additional information, please consult with the Employee Benefits
Department.
10/2015
9/2017
TO: All Participants or Beneficiaries Enrolled in one of ECC’s Group Health Plans
FROM: Employee Benefits Department
RE: Annual Notice –
WHCRAWomen’sHealth&CancerRightsActof1998
This notice serves as the annual notification requirement of the Women’s Health and
Cancer Rights Act of 1998. This law requires group health plans that provide coverage
for mastectomies to also cover reconstructive surgery and prostheses following
mastectomies.
As this Act requires, we have sent you this letter to inform you about the law’s provisions.
The law mandates that a member receiving benefits for a medically necessary
mastectomy who elects breast reconstruction after the mastectomy, will also receive
coverage for:
reconstruction of the breast on which the mastectomy has been performed
surgery and reconstruction of the other breast to produce a symmetrical appearance
prostheses
treatment of physical complications of all stages of mastectomy, including
lymphedemas
This coverage will be provided in consultation with the attending physician and the patient,
and will be subject to the same annual deductibles and coinsurance provisions that apply
for the mastectomy.
If you have any questions about this law or the coverage of mastectomies and
reconstructive surgery, please contact the customer service department of our insurance
carrier / claim administrator at the telephone number shown on your Blue Cross Blue
Shield of Illinois ID card.
TO: All Employees Eligible for the ECC Group Health Plan
FROM: Employee Benefits Department
RE: Annual Notice - Extension of Dependent Coverage to Age 26
This notice is being provided to you by Elgin Community College (ECC) as required by law
to meet requirements under the Patient Protection and Affordable Care Act (PPACA).
Individuals whose coverage ended, or who were denied coverage (or were not eligible for
coverage), because the availability of dependent coverage of children ended before
attainment of age 26 are eligible to enroll in the Elgin Community College Group Health
Care Plan. Individuals may request enrollment for such children for 30 days from the date
of notice. Enrollment will be effective retroactively to July 1, 2011. For more information
contact ECC’s Employee Benefits Department at 847/214-7125 or 847/214-7988.
10/2015
Important Notices
I. Initial Notice About Special Enrollment Rights in Your Group
Health Plan
A federal law called Health Insurance Portability and Accountability Act (HIPAA) requires that we notify you about
very important provisions in the plan. You have the right to enroll in the plan under its “special enrollment provision
without being considered a late enrollee if you acquire a new dependent or if you decline coverage under this plan
for yourself or an eligible dependent while other coverage is in eect and later lose that other coverage for certain
qualifying reasons. Section I of this notice may not apply to certain self-insured, non-federal governmental plans.
Contact your employer or plan administrator for more information.
A. SPECIAL ENROLLMENT PROVISIONS
Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program) If you are declining
enrollment for yourself or your eligible 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 you move out of an HMO service area, or the employer stops
contributing toward your or your dependents’ other coverage). However, you must request enrollment within 31
days aer your or your dependents’ other coverage ends (or move out of the prior plan’s HMO service area, or aer
the employer stops contributing toward the other coverage).
Loss of Coverage For Medicaid or a State Children’s Health Insurance Program
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage
or coverage under a state childrens health insurance program is in eect, you may be able to enroll yourself and
your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must
request enrollment within 60 days aer your or your dependents’ coverage ends under Medicaid or a state childrens
health insurance program.
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption
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 in this plan. However, you must request enrollment within 31 days aer the
marriage, birth, adoption, or placement for adoption.
Eligibility for State Premium Assistance for Enrollees of Medicaid or a State Children’s Health Insurance Program
If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from
Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may
be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days
aer your or your dependents’ determination of eligibility for such assistance.
To request special enrollment or obtain more information, call Customer Service at the phone number on
the back of your Blue Cross and Blue Shield ID card.
II. Additional Notices
Other federal laws require we notify you of additional provisions of your plan.
NOTICES OF RIGHT TO DESIGNATE A PRIMARY CARE PROVIDER FOR NONGRANDFATHERED HEALTH
PLANS ONLY
For plans that require or allow for the designation of primary care providers by participants or beneciaries:
If the plan generally requires or allows the designation of a primary care provider, you have the right to designate any
primary care provider who participates in our network and who is available to accept you or your family members. For
information on how to select a primary care provider, and for a list of the participating primary care providers, call
Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.
For plans that require or allow for the designation of a primary care provider for a child: For children,
you may designate a pediatrician as the primary care provider.
For plans that provide coverage for obstetric or gynecological care and require the designation by a
participant or beneciary of a primary care provider: You do not need prior authorization from the plan or
from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care
from a health care professional in our network who specializes in obstetrics or gynecology. e health care professional,
however, may be required to comply with certain procedures, including obtaining prior authorization for certain
services, following a pre-approved treatment plan, or procedures for making referrals.
For a list of participating health care professionals who specialize in pediatrics, obstetrics or gynecology, call
Customer Service at the phone number on the back of your Blue Cross and Blue Shield ID card.
Blu e Cros s a nd Bl ue Sh iel d o f Illi noi s, a Di visi on of H eal th Car e Ser v ice Cor po rati on a Mu tua l L ega l R ese r ve Comp any, a n Ind epe nde nt Li cens ee of t he Bl ue Cro ss and B lue S hie ld As soc iati on
22963.0415
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