UPHS_Enrollment_Flipbook_Print_Version

Health and Welfare Plan of the University of Pennsylvania Health SystemNotice of Special Enrollment RightsThis notice is being provided to all employees eligible for medical coverage under theHealth and Welfare Plan of the University of Pennsylvania Health System.• If you are declining enrollment for medical coverage for yourself or your dependents (includingyour spouse) because of other health insurance or group health plan coverage, you may beable to enroll yourself and your dependents for medical/RX, dental and vision coverage underthis plan in the following circumstances:• If you or your dependents lose eligibility for that other coverage (or if the employer stopscontributing towards your or your dependents' other coverage),• If you or your dependents lose Medicaid or Children's Health Insurance Program (CHIP)coverage as a result of a loss of eligibility for such coverage, or• If you or your dependents become eligible for a premium assistance subsidy under Medicaid orCHIP.Please Note: This enrollment right does not apply to the Health Care Flexible Spending Account.However, you must request enrollment within 30 days after your or your dependents' othercoverage ends (or after the employer stops contributing toward the other coverage) or within 60days in the case of changes related to Medicaid or CHIP.In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement foradoption, you may be able to enroll yourself and your dependents for medical coverage under thisplan. However, you must request enrollment within 30 days after the marriage, birth, adoption, orplacement for adoption.To request special enrollment, or obtain more information, contact the Corporate BenefitsDepartment at 215-615-2675, option #4.