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Other Important Information

This section gives you more information about changing your elections during the year and when dependent coverage ends, as well as legally-required notices.


Under IRS rules, benefits that you pay for with pre-tax contributions (Medical, Dental, Freestanding Vision, Voluntary Life Insurance coverage for you, and Voluntary AD&D) stay in effect for the full Plan Year (7/1-6/30), unless you have a change in status (Qualified Life Event) and request the change within 30 days (60 days for CHIP).


  • a change in your marital status (such as marriage, divorce, legal separation, or annulment);
  • a change in your dependents for tax purposes (such as birth, legal adoption of your child, placement of a child with you for adoption, or death of a dependent);
  • certain changes in employment status that affect benefits eligibility for you, your spouse, or your child(ren) (such as, termination of employment, start or return from an unpaid leave, a change in worksite, change between full-time and part-time work, or a decrease or increase in hours);
  • your child no longer meets the eligibility requirements; • entitlement to Medicare or Medicaid (applies only to the person entitled to Medicare or Medicaid);
  • a change to comply with a state domestic relations order pertaining to coverage of your dependent child;
  • eligibility for COBRA coverage for you or your dependent spouse or child;
  • a change in place of residence;
  • a significant increase in the cost of coverage or a significant reduction in the benefit coverage under your or your spouse’s health care plan;
  • the addition, elimination, or significant curtailment of coverage;
  • change in your spouse’s or child’s coverage during another employer’s annual enrollment period when the other plan has a different period of coverage; and
  • a loss of coverage from a governmental or educational institution program.

LOSS OF MEDICAID OR CHIP COVERAGE:  If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program (CHIP or SCHIP) is in effect, you may be able to enroll yourself and your dependents for Medical coverage if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.


Health plan coverage for children will end on the last day of the month in which the child reaches age 26 (for Dental, age 19 or age 23 for full-time students).

Extended Medical Coverage—You may enroll your adult child for individual coverage and extend his/her medical coverage from age 26 until age 30 if your child is: unmarried and under age 30 with no dependents of his or her own; a Pennsylvania resident (may be a full-time college student elsewhere); and not enrolled in any other health coverage, whether individual, group, or government provided, including Medicare.

If you choose this option, your child will be covered as an individual, not as your dependent. This will affect your total cost. You will continue to pay your share of the cost for your coverage plus the full cost (no employer contribution) for your child’s coverage. You will need to complete a separate enrollment form for your adult child. See your Benefit Coordinator for more information. There is no requirement that your child be a tax dependent. This extended coverage does not apply to Dental or Vision coverage.



The Keystone POS and Keystone HMO options allow (POS) or require (HMO) you to designate a Primary Care Provider (PCP). You have the right to designate any PCP who participates in the Keystone POS/HMO network and is available to accept you or your family members. Before you complete your enrollment in the Keystone POS or HMO option, you will choose your PCP. Each member of your family can choose a different PCP, and you may choose a pediatrician for your children. You may change your PCP at any time by calling the Member Services number on your ID card or online at

Designated Facilities—PCPs are required to choose one radiology, physical therapy, occupational therapy, and laboratory provider where they will send all their Keystone members. You can view the sites selected by your PCP at

You do not need prior authorization from Keystone Health Plan East or from any other person (including a PCP) to obtain access to obstetrical or gynecological care from a Keystone POS/HMO network healthcare professional who specializes in obstetrics or gynecology. However, that healthcare professional may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a preapproved treatment plan, or procedures for making referrals.

Your local Benefit Coordinator can give you more information about how you select a PCP. A Keystone POS/HMO network directory that includes PCPs and physicians who specialize in obstetrics or gynecology is available from Member Services. You can also access the directory online at or

IMPORTANT— FOR THE KEYSTONE POS OPTION: Benefits will be paid at the lower Self-Referred level if you do not choose a PCP. Benefits also will be paid at the lower level if you use a provider without a PCP referral, even a provider in the Keystone POS/HMO network.


The Women’s Health and Cancer Rights Act requires group health plans to provide coverage for these services to any person receiving benefits in connection with a mastectomy:

  • Reconstruction of the breast on which the mastectomy has been performed,
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance,
  • Prostheses and the treatment of physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes).

If you receive benefits from the Medical Plan for a mastectomy and elect to have reconstructive surgery, then the Medical Plan must provide coverage in a manner determined in consultation with the attending physician and the patient. The Medical Plan’s benefit for breast reconstruction and related services will be the same as the benefit that applies to other services covered by the Medical Plan. While the law requires that we provide this notice, it is important to note that the Company’s Medical Plan already covers these expenses.


Premium Assistance Under Medicaid and 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

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can 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 to find out how to apply. If you qualify, ask your State if it has a program that might help you pay the premiums for an employer sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa. 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 January 31, 2018. Contact your State for more information on eligibility.

NEW JERSEY (Medicaid and CHIP)

NEW YORK (Medicaid)


To see if any other states have added a premium assistance program since January 31, 2019, or for more information on special enrollment rights, contact either:


Employee Benefits Security Administration
1.866.444.EBSA (3272)


Centers for Medicare & Medicaid Services
1.877.267.2323, Menu Option 4, Ext. 61565