Summary of Benefits and Coverage

CareFirst BlueChoice HMO Open Access - Summary of Benefits and Coverage

CareFirst BlueChoice Advantage - Summary of Benefits and Coverage

CareFirst Standard Over 65 - Summary of Benefits and Coverage

Medicare Part D–Creditable Coverage
Important Notice from CCG 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 CCG 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. CCG has determined that the prescription drug coverage offered by the CCG Health Plan is, on average for all plan participants,
expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage.
Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you
later decide to join a Medicare drug plan.

When Can You Join a Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15—December 7.
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 coverage will be affected. Your current coverage pays for other health expenses in
addition to prescription drugs. If you enroll in a Medicare prescription drug plan, you and your eligible dependents will not be eligible to
receive all of your current health and prescription drug benefits. If you drop your current coverage with CCG and enroll in Medicare
prescription drug coverage, you may enroll back into the CCG Health Plan during the Open Enrollment period or if you experience a
qualifying event. If you do decide to join a Medicare drug plan and drop your current CCG Health Plan coverage, be aware that you and your
dependents may not be able to get this coverage back.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with CCG 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 19 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…
For further information contact the Human Resources Department.
NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage
through CCG changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy
of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
⚫ Visit www.medicare.gov
⚫ Call your State Health Insurance Assistance Program 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).

HIPAA Notice of Availability of Privacy Practices
The CCG Health Plan (Plan) maintains a Notice of Privacy Practices that provides information to individuals whose protected health
information (PHI) will be used or maintained by the Plan. The Notice describes the legal obligations of the CCG group health plan (the
“Plan”) and your legal rights regarding your protected health information held by the Plan under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). Among other things, the Notice describes how your protected health information may be used or
disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law. If
you would like a copy of the Plan's Notice of Privacy Practices, please contact Human Resources.

HIPAA Notice of Special Enrollment
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.
Also, you may be entitled to special enrollment rights pursuant to the Children’s Health Insurance Program Reauthorization Act of 2009
(the Act) if you or your dependents:
1. Lose coverage under a Medicaid or State Plan; or
2. Become eligible for group health premium assistance under a Medicaid plan or State Plan.
If a special enrollment right is provided pursuant to the Act, you may change your election consistent with such special enrollment right
within 60 days as long as the election is made consistent with the special enrollment.

Waiver of Coverage
If you elect to waive coverage for yourself or your dependents (including your spouse), you acknowledge that you and your spouse and/or
dependent child(ren) can only enroll later during an annual Open Enrollment period. An exception to this is if you and your spouse and/or
dependent child(ren) are entitled to enroll in accordance with the “Special Enrollment Rights” described above.
To request special enrollment or obtain more information, contact Human Resources.

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 your State may have a premium assistance program that can help pay for
coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for
these premium assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP, to see if your state has a premium assistance program, or for more
information on special enrollment rights, contact the U.S. Department of Labor or the U.S. Department of Health and Human Services or the
Employee Benefits Security Administration Centers for Medicare & Medicaid Services at 1-866-444-EBSA (3272), 1-877-267- 2323, Menu
Option 4, Ext. 61565.
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, you can 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, you can ask the 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).

Women’s Health & Cancer Rights Act (WHCRA)
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act
of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultations
with the attending physician and the patient, for:
• All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses; and
• Treatment of physical complications of the mastectomy, including lymphedemas.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided
under this plan. Contact Human Resources for more information.

Model Wellness Program Disclosure
Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all
employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an
opportunity to earn the same reward by different means. Contact HR and we will work with you (and, if you wish, with your doctor) to find a
wellness program with the same reward that is right for you in light of your health status.

Grandfathered Plan

The Charles County Government health insurance plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act).  As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.  Being a grandfathered health plan means that the health insurance plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.  Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at Charles County Government Benefits Department at 301-645-0585.  You may also contact the U.S. Department of Health and Human Services at https://www.healthcare.gov/health-care-law-protections/grandfathered-plans/.