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Understanding your coverage
Please reference the disclaimers, details and informative downloads on this page when you have questions about your SBMA health insurance coverage.
Non Creditable Coverage Disclosure
Important Notice From Staff Benefits Management & Administrators 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 Staff Benefits Management & Administrators 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. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are three important things you need to know about your current coverage and Medicare’s prescription drug coverage:
- Medicare prescription drug coverage became available in 2006 to everyone with 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.
- Staff Benefits Management & Administrators has determined that the prescription drug coverage offered by the Plan Sponsor is, on average for all plan participants, NOT expected to pay out as much as standard Medicare prescription drug coverage Therefore, your coverage is considered Non-Creditable Coverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare drug plan, than if you only have prescription drug coverage from the Plan Sponsor. This also is important because it may mean that you may pay a higher premium (a penalty) if you do not join a Medicare drug plan when you first become eligible.
- You can keep your current coverage from the Plan However, because your coverage is non- creditable, you have decisions to make about Medicare prescription drug coverage that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Read this notice carefully – it explains your options.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15TH to December 7th.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
Since the coverage under the Plan Sponsor, is not creditable, depending on how long you go without creditable prescription drug coverage you may pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer without prescription drug coverage that’s creditable, 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 (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
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 Staff Benefits Management & Administrators coverage will not be affected. You may continue to use your prescription drug coverage through Staff Benefits Management & Administrators as your primary option. Your Medicare drug plan will serve as a secondary coverage option for any prescribed drugs that are not covered by the Plan Sponsor. NOTE: You will need to inform your healthcare provider/pharmacist with information pertaining to your Medicare drug plan. Staff Benefits Management & Administrators is not able to provide this information to providers on your behalf.
If you do decide to join a Medicare drug plan and drop your current Staff Benefits Management & Administrators coverage, be aware that you and your dependents will only be able to get this coverage back during your Plan Sponsor’s next open enrollment period.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Call Staff Benefits Management & Administrators at (888) 505-7724. NOTE: You’ll get this notice each year before the next period you can join a Medicare drug plan and if this coverage through Staff Benefits Management & Administrators 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 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).
COBRA Rights Notice
GENERAL NOTICE OF YOUR RIGHTS
GROUP HEALTH CONTINUATION COVERAGE UNDER COBRA
THIS LETTER IS FOR YOUR INFORMATION ONLY. PLEASE RETAIN FOR FUTURE REFERENCE. THERE HAS NOT BEEN A CHANGE IN YOUR STATUS WITH YOUR COMPANY.
This letter contains important information about your employee benefits plan(s). Please read the entire letter.
On April 7, 1986, a federal law called COBRA was enacted (Public Law 99-272, Title X), requiring that most employers sponsoring group health plans offer employees and their families (qualified beneficiary/ies) the opportunity for a temporary extension of health coverage at group rates in certain instances where coverage under the plan would otherwise end. This notice is intended to inform you, in a summary fashion, of your rights as a qualified beneficiary and obligations under COBRA. You should take the time to read this notice carefully. This notice does not fully describe COBRA or other rights under your health plan. For additional information you should visit the Department of Labor website (www.dol.gov) for more information on COBRA. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.
As a covered employee, you have a right to choose COBRA if you lose your group health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part).
If you are the spouse of an employee covered by the Group Health Plan, you have the right to choose COBRA for yourself if you lose group health coverage under the Group Health Plan for any of the following reasons:
- The death of your spouse;
- A termination of your spouse’s employment (for reasons other than gross misconduct) or reduction in your spouse’s hours of
- Divorce or legal separation from your spouse; or
- Your spouse becomes entitled to
In the case of a dependent child of an employee covered by the Group Health Plan, he or she has the right to choose COBRA if the Group Health Plan is lost for any of the following reasons:
- The death of the employee;
- A termination of the employee’s employment (for reasons other than gross misconduct) or reduction in the employee’s hours of
- The employee’s divorce or legal separation;
- The employee became entitled to Medicare prior to his/her qualifying event; or
- The dependent child ceases to be a dependent child under the Group Health
Sometimes, filing a bankruptcy under Title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to your employer and that bankruptcy results in the loss of coverage of any retired employee under the Group Health Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Group Health Plan.
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 doesn’t accept late enrollees.
Under COBRA, the employee or a family member has the responsibility to inform their employer of a divorce, legal separation, or a child losing dependent status under the Group Health Plan within 60 days of the date of the event. Your employer has the responsibility to notify the administrator of the employee’s death, termination, and reduction in hours of employment or Medicare entitlement. When the administrator is notified that one of these events has happened, the administrator will in turn notify you that you have the right to choose COBRA. Under COBRA, you have at least 60 days from the later of the date you would lose coverage because of one of the qualifying events described above or the date of notification of your rights under COBRA, whichever is later, to inform your employer’s plan administrator that you want to continue coverage under COBRA.
If you elect COBRA, your employer is required to give you and your covered dependents, if any, coverage that is identical to the coverage provided under the plan to similarly situated employees or family members. Under COBRA, you may have to pay all or part of the premium for your continuation coverage. If you do not choose COBRA on a timely basis, your group health insurance coverage will end.
Period of Coverage
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
COBRA requires that you be afforded the opportunity to maintain coverage for 36 months unless you lost group health coverage because of a termination of employment or reduction in hours. In that case, the required COBRA period is 18 months. Also, if you or your spouse gives birth to or adopts a child while on COBRA, you will be allowed to change your coverage status to include the child. The 18-month period may be extended to 29 months if an individual is determined by the Social Security Administration (SSA) to be disabled (for Social Security purposes) as of the termination or reduction in hours of employment or within 60 days thereafter. To benefit from this extension, a qualified beneficiary must notify their employer’s plan administrator of that determination within 60 days and before the end of the original 18-month period. The affected individual must also notify their employer’s plan administrator within 30 days of any final determination that the individual is no longer disabled. If the original event causing the loss of coverage was a termination (other than for gross misconduct) or a reduction in hours, another extension of the 18-month continuation period may occur, if during the 18 months of COBRA coverage, a qualified beneficiary experiences certain secondary qualifying events:
- Divorce or legal separation
- Medicare entitlement
- Dependent child ceasing to be a dependent
If a second qualifying event does take place, COBRA provides that the qualified beneficiary may be eligible to extend COBRA up to 36 months from the date of the original qualifying event. If a second qualifying event occurs, it is the qualified beneficiary’s responsibility to inform their employer’s plan administrator within 60 days of the event. In no event, however, will COBRA last beyond three years from the date of the event that originally made the qualified beneficiary eligible for COBRA.
Alternate Recipients Under QMCSOs
A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by their employer during the covered employee’s period of employment with their employer is entitled to the same rights to elect COBRA as an eligible dependent child of the covered employee.
Are there other coverage options besides COBRA Continuation Coverage
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
Plan Contact Information
Questions concerning your Plan, or your COBRA continuation coverage rights, should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.
To ensure that all covered individuals receive information properly and timely, it is important that you notify our Customer Service Department at (888) 505-7724 of any change in dependent status or any address change of any family member as soon as possible. Certain changes must be submitted to us in writing. Failure on your part to notify us of any changes may result in delayed notification or loss of continuation of coverage options.
If you have any questions about COBRA, please contact our Customer Service Department at (888) 505-7724 during business hours.
General Notice of Privacy Practices
This notice is for informational purposes only – no action is required on your part.
Staff Benefits Management and Administrators (SBMA) is committed to protecting your privacy. It is important for you to understand how SBMA collects, uses, maintains and discloses personal information and data collected from its members.
This notice provides an overview of SBMA’s privacy policies, your rights under those policies and the legal guidelines that govern the policies.
What Information is Collected
SBMA collects the following information from all members and associated dependents:
- Full name of member which may include a middle name or middle initial
- Date of birth
- Social security number or other applicable tax identification numbers
- Mailing address
- Date of hire (preferred but not required)
- Associated dependents’ names, dates of birth and social security numbers or other applicable tax identification number
How Information is Collected
SBMA receives member information in the following ways:
- Directly from members either via application or online portal
- From plan sponsors
- From associated contractors of plan sponsors
What Information is Disclosed and with Whom is it Disclosed
SBMA discloses any combination of the information listed above, as well as certificate numbers generated by SBMA at the time of enrollment, to affiliated and/or non-affiliated third parties as necessary to administer, and provide servicing for, products and/or services you have elected.
We do not disclose any information for the purposes of marketing or with any affiliated and/or non-affiliated third parties or business associates for products and/or services you have not elected.
WE ARE REQUIRED BY LAW TO PROTECT MEDICAL INFORMATION ABOUT YOU
SBMA is required by law to adhere to The Health Insurance Portability and Accountability ACT (HIPAA) in protecting your medical information, how this information can be used and how you can get access to this information.
We are further required to disclose our privacy practices and notify any affected members in the event of a breach in the protection of your private information.
SBMA maintains HIPAA compliancy and requires HIPAA certification of all employees and officers of the company with access to your personal and medical information.
SBMA only contracts with agencies and business associates who maintain at least the same level of HIPAA compliance to ensure your information is protected.
We do not disclose any of your medical information, to anyone, unless authorized by you in writing, or as permitted or required by law, or under any of the following circumstances:
- MEDICAL TREATMENT We may disclose information about your medical coverage to physicians, hospitals or any other health care provider or facility involved in your care including pharmacies and may include information disclosed for the purposes of explaining coverage type, providing preauthorization or determining the medical necessity of a service or treatment plan and to process an pay claims covered under your plan.
- PLAN ADMINISTRATION We may disclose information as necessary, and as permitted by law, to provide administration, servicing and general operations for your This includes enrollment, fulfillment, government reporting, compliance, commission payments to agents, reinsurance, fraud prevention, auditing, customer service, premium collection and other operations related to the administration of your health plan.
- THIRD PARTY AND BUSINESS ASSOCIATIONS We may disclose information to affiliated and/or non-affiliated third parties, business associates or agencies for the purposes of assisting us with the operation and administration of your health plan. SBMA contracts with outside associates and organizations for the purposes of fulfillment, auditing, compliance, reinsurance, legal services, claims administration and adjudication, government reporting, information technology and security vendors, ancillary products and services vendors and other governmental or legal agencies as required by law.
- PLAN SPONSORS We may disclose information to the plan sponsor of your group health plan for the purposes of premium collection, claims funding, enrollment verification, customer service, government reporting and other operations related to the administration of your Please note, SBMA may not disclose medical information to the plan sponsor that may be used for employment related decisions, benefit eligibility determinations or in any manner not permitted by state or federal law.
- CONTRACTING CHANGES, MERGERS AND ACQUISITIONS We may disclose your information as part of a potential change in contracting for example with network providers or pharmacy benefit managers for the general servicing and administration of your plan. We may also disclose your information as part of a potential sale, merger or acquisition of our business.
- LEGAL AND GOVERNMENTAL We may disclose information for any purpose when required by law or for law enforcement activities including criminal investigations or proceedings; public health services including medical support orders, child abuse, elder abuse, domestic abuse, neglect or other criminal activities. Information may also be disclosed by administrative order or subpoena, governmental requirements for military branches or correctional facilities, law enforcement or workers compensation agencies for the purposes of fraud investigations or by request from the Department of Labor.
Your rights under this policy are as follows:
- MEDICAL INFORMATION SHARING You have the right to authorize the sharing of your protected health information with anyone you so choose by completing the HIPAA Privacy Authorization This form may be requested via phone or by mail at the phone number/address at the bottom of this page. Authorizations may be enacted or revoked at your request at any time. SBMA is not responsible for the misuse of your protected information by parties designated by your authorization.
- REQUESTS FOR INFORMATION You have the right to request any information SBMA retains on your behalf which includes member certificate number, effective date of coverage, plan information including policy documents, summaries of benefits and services and marketing materials, member and dependent demographic information, claim status and information including copies of explanation of benefit documents and fulfilment materials including copies of member identification cards, welcome letter and additional fulfilment inserts. Requests for copies of policy documents are available at no charge. Anyone may request a copy of this privacy notice, at any time, for any reason.
- ALTERNATIVE COMMUNICATIONS You the have the right to request that SBMA send communications including your information by alternative means which may include contact by an alternative phone number, email address or mailing address. We will make every effort to accommodate reasonable requests. You may request alternative communication options via phone or by mail at the phone number/address listed at the bottom of this page.
- CHANGE OF INFORMATION You have the right to request changes or provide updates to your personal information which may include demographic information. You may not however request changes to your benefit plan including cancelation of coverage. SBMA prefers all change of information requests be directed to your plan sponsor prior to being communicated to SBMA reserves the right to share any change of information requests with the plan sponsor.
- APPEALS AND COMPLAINTS You have the right to appeal or file a complaint for any situation involving your personal information including claim status, denied requests, or any misuse of your private information. If you believe your privacy rights have been violated, you may submit a written complaint to our Member Compliance Department at the address below. All complaints will be investigated by SBMA within 90 days of post-marked date on the complaint letter. You may also file a written complaint with the Secretary of the United States Department of Health and Human Services within 180 days of the violation of your SBMA may not take any adverse action against you as a result of filing a complaint.
(888) 505-7724 option 2 (members will be required to verify their identity by providing specific policy information) calls are recorded for quality purposes
or by mail at:
Staff Benefits Management and Administrators Member Compliance Department
2307 Fenton Pkwy # 107-126 San Diego, CA 92108
Please include your full name, social security number or certificate number, phone number and the nature of your request or complaint.
THIS NOTICE IS REQUIRED BY FEDERAL LAW. IT IS AVAILABLE TO POLICY MEMBERS, PLAN SPONSORS AND THE GENERAL PUBLIC. RECEIPT OF THIS NOTICE IS NOT EVIDENCE OF COVERAGE.