2017-2018 The HydraFacial Company Benefits Summary DRAFT

Requ i red Federal Not i ces , CONT I NUED

P R E M I U M A S S I S T A N C E U N D E R M E D I C A I D A N D T H E C H I L D R E N ’ S H E A L T H I N S U R A N C E

P R O G R A M ( C H I P ) , C O N T I N U E D

SOUTH CAROLINA – Medicaid

Website:

http://www.scdhhs.gov

Phone: 1-888-549-0820

SOUTH DAKOTA - Medicaid

Website:

http://dss.sd.gov

Phone: 1-888-828-0059

TEXAS – Medicaid

Website:

https://www.gethipptexas.com/

Phone: 1-800-440-0493

UTAH – Medicaid and CHIP

Website:

http://health.utah.gov/chip

Phone: 1-877-543-7669

VERMONT– Medicaid

Website:

http://www.greenmountaincare.org/

Phone: 1-800-250-8427

VIRGINIA – Medicaid and CHIP

Medicaid and CHIP Website:

http://www.coverva.org/programs_premium_assistan ce.cfm Med

icaid Phone: 1-800-432-5924

CHIP Phone: 1-855-242-8282

WASHINGTON – Medicaid

Website:

http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm

Phone: 1-800-562-3022 ext. 15473

WEST VIRGINIA – Medicaid

Website:

www.dhhr.wv.gov/bms/

Phone: 1-877-598-5820, HMS Third Party Liability

WISCONSIN – Medicaid

Website:

https://www.dhs.wisconsin.gov/badgercareplus/p- 10095.htm

Phone: 1-800-362-3002

WYOMING – Medicaid

Website:

http://wyequalitycare.acs-inc.com/

Phone: 307-777-7531

To see if any other states have added a premium assistance program since July 31, 2016, or for more information on

special enrollment rights, you can contact either:

U.S. Department of Labor Employee Benefits Security Administration

www.dol.gov/ebsa

(866) 444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services

www.cms.hhs.gov

(877) 267-2323, Menu Option 4 Ext. 61565

OMB Control Number 1210-0137 (expires 10/31/2016

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