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Home My WebLink AboutAnnual Notice 2026l - 2026 ANNUAL NOTICES • • • Questions? • • • 800.537,7790 • • • healthbenefits@sdrma.org www.sdrma.org THIS PAGE INTENTIONALLY LEFT BLANK SDRMA Health Benefits 2026 Annual Notice Preface to Medicare Part D Notice ..................................................................................................................................................................................1 Medicare Part D Notice ............................................................................................................................................................................................................2 When Can You Join a Medicare Drug Plan? ............................................................................................................................................................2 What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan? ...................................................2 When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? .......................................................................3 For More Information about Your Options under Medicare Prescription Drug Coverage ..................................................3 Women’s Health and Cancer Rights Act .....................................................................................................................................................................5 Newborns and Mothers’ Health Protection Act.....................................................................................................................................................5 Notice of Availability of HIPAA Privacy Notice .......................................................................................................................................................7 HIPAA Notice of Special Enrollment Rights .............................................................................................................................................................7 Affordable Care Act (ACA) 1557 Notice ........................................................................................................................................................................7 Premium Assistance Under Medicaid and the Childrens’ Health Insurance Program (CHIP) ..........................................9 Notice of Choice of Providers ............................................................................................................................................................................................13 Rules for Benefit Changes During the Year ............................................................................................................................................................13 sdrma.org SE C T I O N 1 PREFACE TO MEDICARE PART D NOTICE MEDICARE PART D Back toTop 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 1 sdrma.org PREFACE It is important to understand the Medicare Part D Notice is designed to inform individuals currently eligible for or soon to become eligible for Medicare that the prescription drug benefits provided in the Public Risk Innovation, Solutions, and Management (PRISM) Small Group Health Program are deemed to be a creditable alternative to Medicare Part D coverage. All Medicare eligible individuals who are currently covered through the PRISM Health Small Group Program or who are eligible to apply for coverage through the PRISM should receive this notice at least once per year. For easy reference, below is a list of who should be provided a copy of this annual notice: 1. Individuals enrolled in Active Medical coverage 2. Individuals eligible, but NOT enrolled in Active Medical coverage (waived coverage) 3. Individuals enrolled in Early Retiree Medical coverage (where applicable) 4. Individuals enrolled in Medicare Retiree Medical coverage (where applicable) Back toTop 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 2 sdrma.org MEDICARE PART D NOTICE Important Notice from Public Risk Innovation, Solutions, and Management (PRISM) 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 Public Risk Innovation, Solutions, and Management’s (PRISM) 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. Your plan has determined that the prescription drug coverage offered by PRISM 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 15th to December 7th. 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 Public Risk Innovation, Solutions, and Management (PRISM) coverage willnot be affected. See below for more information about what happens to your current coverage if you join a Medicare drug plan. Since the existing prescription drug coverage under Public Risk Innovation, Solutions, and Management (PRISM) is creditable (e.g., as good as Medicare coverage), you can retain your existing prescription drug coverage and choose not to enroll in a Part D plan; or you can enroll in a Part D plan as a supplement to, or in lieu of, your existing prescription drug coverage. If you do decide to join a Medicare drug plan and drop your Public Risk Innovation, Solutions, and Management (PRISM) prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. Back toTop 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 3 sdrma.org 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 Public Risk Innovation, Solutions, and Management (PRISM) 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 YOUR OPTIONS UNDER MEDICARE PRESCRIPTION DRUG COVERAGE… Contact the person listed below for further information. 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 Public Risk Innovation, Solutions, and Management (PRISM) changes. You also may request a copy of this notice at any time. 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 800.MEDICARE (800.633.4227). TTY users should call 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 socialsecurity.gov, or call them at 800.772.1213 (TTY 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: 10/01/2025 Name of Entity/Sender: Otay Water District Contact.Position/Office: Human Resources Address: 2554 Sweetwater Springs Blvd. Spring Valley, CA 91978 Phone Number: 619-670-2222 Back toTop SE C T I O N 1 WOMEN’S HEALTH AND CANCER RIGHTS ACT NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT Back toTop 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 5 sdrma.org WOMEN’S HEALTH AND CANCER RIGHTS ACT The Women’s Health and Cancer Rights Act (WHCRA) requires employer groups to notify participants and beneficiaries of the group health plan, of their rights to mastectomy benefits under the plan. Participants and beneficiaries have rights for coverage to be provided in a manner determined in consultation with the attending Physician 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 lymphedema. These benefits are subject to the same deductible and co-payments applicable to other medical and surgical procedures provided under this plan. You can contact your health plan’s Member Services for more information. NEWBORN’S AND MOTHER’S HEALTH PROTECTION ACT Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If you would like more information on maternity benefits, call your plan administrator. Back toTop SE C T I O N 1 NOTICE OF AVAILABILITY OF HIPAA PRIVACY NOTICE HIPAA NOTICE OF SPECIAL ENROLLMENT RIGHTS FOR MEDICAL/HEALTH PLAN COVERAGE AFFORDABLE CARE ACT 1557 NOTICE Back toTop 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 7 sdrma.org NOTICE OF AVAILABILITY OF HIPAA PRIVACY NOTICE The federal Health Insurance Portability and Accountability Act (HIPAA) requires that we periodically remind you of your right to receive a copy of the Insurance Carriers’ HIPAA Privacy Notices. You can request copies of the Privacy Notices by contacting the Human Resources Department or by contacting the insurance carriers directly. HIPAA NOTICE OF SPECIAL ENROLLMENT RIGHTS FOR MEDICAL/HEALTH PLAN COVERAGE If you decline enrollment in Public Risk Innovation, Solutions, and Management’s (PRISM) health plan for you or your dependents (including your spouse) because of other health insurance or group health plan coverage, you or your dependents may be able to enroll in Public Risk Innovation, Solutions, and Management’s (PRISM) health plan without waiting for the next open enrollment period if you: •Lose other health insurance or group health plan coverage. You must request enrollment within [30/31] days after the loss of other coverage.•Gain a new dependent as a result of marriage, birth, adoption, or placement for adoption. You must request [medical plan OR health plan] enrollment within [30/31] days after the marriage, birth, adoption, or placement for adoption.•Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer eligible. You must request medical plan enrollment within 60 days after the loss of such coverage. If you request a change due to a special enrollment event within the [30/31] day timeframe, coverage will be effective the date of birth, adoption or placement for adoption. For all other events, coverage will be effective the first of the month following the qualifying event. In addition, you may enroll in Public Risk Innovation, Solutions, and Management’s (PRISM) medical plan if you become eligible for a state premium assistance program under Medicaid or CHIP. You must request enrollment within 60 days after you gain eligibility for medical plan coverage. If you request this change, coverage will be effective the first of the month following your request for enrollment. Specific restrictions may apply, depending on federal and state law. Note: If your dependent becomes eligible for special enrollment rights, you may add the dependent to your current coverage or change to another health plan. AFFORDABLE CARE ACT 1557 NOTICE Non-discrimination statement for significant publications and signification communications: Public Risk Innovation, Solutions, and Management complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Back toTop SE C T I O N 1 PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) Back toTop 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 9 sdrma.org PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1.877.KIDSNOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1.866.444.EBSA (3272). 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, 2021. Contact your State for more information on eligibility— Back toTop STATE PROGRAM WEBSITE CONTACTINFORMATION ALABAMA Medicaid http://myalhipp.com/1.855.692.5447 ALASKA Medicaid The AK Health Insurance Premium Payment Program http://myakhipp.com/ Medicaid Eligibility http://dhss.alaska.gov/dpa/ Pages/medicaid/default.aspx 1.866.251.4861 Email: CustomerService@MyAKHIPP. com ARKANSAS Medicaid http://myarhipp.com/1.855.MyARHIPP (855.692.7447) CALIFORNIA Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp 916.445.8322 Email: hipp@dhcs.ca.gov COLORADO Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) Health First Colorado https://www.healthfirst colorado.com/ CHP+: https://www.colorado.gov/pacif- ic/hcpf/child- health-plan-plus Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pa- cific/hcpf/health-insurance- buy-program Health First Colorado Member Contact Center: 1.800.221.3943 State Relay 711 CHP+ Customer Service: 1.800.359.1991 State Relay 711 HIBI Customer Service: 1.855.692.6442 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 10 sdrma.org STATE PROGRAM WEBSITE CONTACTINFORMATION FLORIDA Medicaid https://www.flmedicaidtplrecov- ery.com/flmedicaidtplrecovery. com/hipp/index.html 1.877.357.3268 GEORGIA Medicaid https://medicaid.georgia.gov/ health-insurance- premium- payment-program-hipp 678.564.1162 ext 2131 INDIANA Medicaid Healthy Indiana Plan for Low.Income Adults 19.64 http://www.in.gov/fssa/hip/ All other Medicaid https://www.in.gov/medicaid/ 1.877.438.4479 Phone 1.800.457.4584 IOWA Medicaid and CHIP (Hawki) Medicaid: https://dhs.iowa.gov/ ime/members Hawki:http://dhs.iowa.gov/ Hawki HIPP:https://dhs.iowa.gov/ime/ members/medicaid-a- to-z/hipp Medicaid 1.800.338.8366 Hawki 1.800.257.8563 HIPP 1.888.346.9562 KANSAS Medicaid https://www.kancare.ks.gov/1.800.792.4884 KENTUCKY Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI.HIPP) https://chfs.ky.gov/agencies/ dms/member/ Pages/kihipp.aspx KCHIP https://kidshealth.ky.gov/Pages/ index.aspx Kentucky Medicaid https://chfs.ky.gov 1.855.459.6328 Email: KIHIPP.PROGRAM@ky.gov 1.877.524.4718 LOUISIANA Medicaid www.medicaid.la.gov www.ldh.la.gov/lahipp Medicaid hotline 1.888.342.6207 LaHIPP 1.855.618.5488 MAINE Medicaid Enrollment https://www.maine.gov/dhhs/ ofi/applications-forms Private Health Insurance Premium https://www.maine.gov/dhhs/ ofi/applications-forms 1.800.442.6003 TTY: Maine relay 711 1.800.977.6740 TTY: Maine relay 711 Back toTop 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 11 sdrma.org Back toTop STATE PROGRAM WEBSITE CONTACTINFORMATION MASSACHUSETTS Medicaid and CHIP https://www.mass.gov/info- details/masshealth- premium- assistance-pa 1.800.862.4840 MINNESOTA Medicaid https://mn.gov/dhs/people-we- serve/children-and-families/ health-care/health-care-pro- grams/programs-and-services/ other-insurance.jsp 1.800.657.3739 MISSOURI Medicaid http://www.dss.mo.gov/mhd/ participants/pages/hipp.htm 573.751.2005 MONTANA Medicaid http://dphhs.mt.gov/Montana- HealthcarePrograms/HIPP 1.800.694.3084 NEBRASKA Medicaid http://www.ACCESSNebraska. ne.gov 1.855.632.7633 Lincoln: 402.473.7000 Omaha: 402.595.1178 NEVADA Medicaid http://dhcfp.nv.gov 1.800.992.0900 NEW HAMPSHIRE Medicaid https://www.dhhs.nh.gov/ programs-services/medicaid/ health-insurance-premium- program 603.271.5218 Toll free number for the HIPP program: 1.800.852.3345, ext 5218 NEW JERSEY Medicaid and CHIP Medicaid https://www.nj.gov/humanser- vices/dmahs/clients/medicaid/ CHIP http://www.njfamilycare.org/ index.html Medicaid 609.631.2392 CHIP Phone 1.800.701.0710 NEW YORK Medicaid https://www.health.ny.gov/ health_care/medicaid/1.800.541.2831 NORTH CAROLINA Medicaid https://medicaid.ncdhhs.gov/919.855.4100 NORTH DAKOTA Medicaid http://www.nd.gov/dhs/ services/medicalserv/ medicaid/ 1.844.854.4825 OKLAHOMA Medicaid and CHIP http://www. insureoklahoma.org 1.888.365.3742 OREGON Medicaid http://healthcare.oregon.gov/ Pages/index.aspx http://www.oregonhealthcare. gov/index-es.html 1.800.699.9075 PENNSYLVANIA Medicaid https://www.dhs.pa.gov/Ser- vices/Assistance/Pages/HIPP- Program.aspx 1.800.692.7462 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 12 sdrma.org STATE PROGRAM WEBSITE CONTACTINFORMATION RHODE ISLAND Medicaid http://www.eohhs.ri.gov/1.855.697.4347, or 401.462.0311 (Direct Rite Share Line) SOUTH CAROLINA Medicaid https://www.scdhhs.gov 1.888.549.0820 SOUTH DAKOTA Medicaid and CHIP http://dss.sd.gov 1.888.828.0059 TEXAS Medicaid http://gethipptexas.com/1.800.440.0493 UTAH Medicaid and CHIP Medicaid https://medicaid.utah.gov/ CHIP http://health.utah.gov/chip 1.888.222.2542 VERMONT Medicaid http:// www.greenmountaincare.org/1.800.250.8427 VIRGINIA Medicaid and CHIP https://www.coverva.org/en/ famis-select https://www.coverva.org/en/ hipp Medicaid 1.800.432.5924 CHIP 1.800.432.5924 WASHINGTON Medicaid https://www.hca.wa.gov/1.800.562.3022 WEST VIRGINIA Medicaid http://mywvhipp.com/1.855.MyWVHIPP (1.855.699.8447) WISCONSIN Medicaid and CHIP https://www.dhs.wisconsin.gov/ badgercareplus/ p- 10095.htm 1.800.362.3002 WYOMING Medicaid https://health.wyo.gov/health- carefin/medicaid/programs- and-eligibility/ 1.855.294.2127 Back toTop To see if any other states have added a premium assistance program since July 31, 2021, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1.866.444.EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1.877.267.2323, Menu Option 4, Ext. 61565 20 2 6 S D R M A H E A LTH B E N E F I T S AN N U A L N O TI C E S - 13 sdrma.org Back toTop NOTICE OF CHOICE OF PROVIDERS Public Risk Innovation, Solutions, and Management (PRISM) generally 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, contact your plan administrator. For children, you may designate a pediatricia n as the primary care provider. You do not need prior authorization from Public Risk Innovation, Solutions, and Management (PRISM) 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. The 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 obstetrics or gynecology, contact your plan administrator. RULES FOR BENEFIT CHANGES DURING THE YEAR Other than during annual open enrollment, you may only make changes to your benefit elections if you experience a qualified status change or qualify for a “special enrollment”. If you qualify for a mid-year benefit change, you may be required to submit proof of the change or evidence of prior coverage. Qualified Status Changes Include:•Change in legal marital status, including marriage, divorce, legal separation, annulment, and death of a spouse•Change in number of dependents, including birth, adoption, placement for adoption, or death of a dependent child•Change in employment status that affects benefit eligibility, including the start or termination of employment by you, your spouse, or your dependent child•Change in work schedule, including an increase or decrease in hours of employment by you, your spouse, or your dependent child, including a switch between part-time and full- time employment or ceasing to satisfy them•Change in a child’s dependent status, either newly satisfying the requirements for dependent child status or ceasing to satisfy them•Change in place of residence or worksite, including a change that affects the accessibility of network providers•Change in your health coverage or your spouse’s coverage attributable to your spouse’s employment•Change in an individual’s eligibility for Medicare or Medicaid•A court order resulting from a divorce, legal separation, annulment, or change in legal custody (including a Qualified Medical Child Support Order) requiring coverage for your child•An event that is a “special enrollment” under the Health Insurance Portability and Accountability Act (HIPAA) including acquisition of a new dependent by marriage, birth or adoption, or loss of coverage under another health insurance plan.•An event that is allowed under the Children’s Health Insurance Program (CHIP) Reauthorization Act. Under provisions of the Act, employees have 60 days after the following events to request enrollment:•Employee or dependent loses eligibility for Medicaid (known as Medi-Cal in CA) or CHIP (known as Healthy Families in CA).•Employee or dependent becomes eligible to participate in a premium assistance program under Medicaid or CHIP Two rules apply to making changes to your benefits during the year: 1.Any changes you make must be consistent with the change in status, AND 2.You must make the changes within 30/31 days of the date the event (marriage, birth, etc.) occurs (unless otherwise noted above).