PACIFIC UNION COLLEGE’S 2012 IMPORTANT ANNUAL NOTICES
We recommend that you review the attached notices to determine if any of them apply to you.
Medicare Part D
•
Group health plans providing prescription drug coverage must provide a notice to any individual covered by or
eligible for the group health plan may be eligible for Medicare (an “eligible individual”). The notice must explain
whether the plan’s prescription drug coverage is creditable. Coverage is creditable if it is actuarially equivalent to
coverage available under the standard Medicare Part D program. In order to satisfy the distribution timing
requirements, the notice is generally distributed upon an individual’s enrollment in the plan, each year during
open enrollment and during the plan year if the status of the coverage changes (either for the plan as a whole or
for the individual).
Summary of Benefits Coverage
Women’s Health & Cancer Rights Act (WHCRA)

Notification that your health plan offers coverage for mastectomies and provides certain additional mastectomyrelated benefits.
HIPAA Notice of Special Enrollment

Outlines the circumstances under which you and your dependents may make changes to your health plan
elections.
HIPAA Privacy Notice
Designation of Primary Care Provider

Provides primary care provider rights under ACA
Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA)

Employers must provide the initial Employer Notice by the later of
(1) the first day of the first plan year after February 4, 2010; or
(2) May 1, 2010. (For calendar-year plans, the notice must be provided by January 1, 2011.)

The Employer Notice requirements include the following:
(1) The Notice must be provided annually;
(2) The Notice must be provided on an automatic basis and free of charge; and 3. The Notice must inform each
employee (regardless of enrollment status) of potential opportunities for premium assistance in the state in
which the employee resides. Note that a separate mail requirement is not necessary. Plans can furnish the
notice along with open enrollment materials or a Summary Plan Description
General Notice of Pre-Existing Condition Exclusion

Notification that your health plan imposes a pre-existing condition exclusion and the circumstances under which
this exclusion may apply to you or your dependents.
IRS rules for Qualifying Child or Qualifying Relative
•
Return signed notice if your dependent child(ren) are over the age of 27 and/or do not meet the IRS definition of
a Qualifying Child or Qualifying Relative.
•
Provides additional enrollment rights under the Affordable Care Act
MEDICARE PART D – CREDITABLE COVERAGE
Important Notice from PACIFIC UNION COLLEGE 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 PACIFIC UNION COLLEGE 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. PACIFIC UNION COLLEGE has determined that the prescription drug coverage offered by the PACIFIC UNION
COLLEGE HEALTH PLAN 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 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 current coverage will not be affected.
If you do decide to join a Medicare drug plan and drop your current PACIFIC UNION COLLEGE coverage, be aware that
you and your dependents will be able to get this coverage back (at the annual open enrollment and as the result of a
qualified life status event).
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 PACIFIC UNION COLLEGE 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 This Notice Or Your Current 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 PACIFIC UNION COLLEGE
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 www.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 1-800772-1213 (TTY 1-800-325-0778).
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).
Contact: Galyn Bowers, Director of Human Resources
Address: Pacific Union College, Financial Administration, One Angwin Avenue, Angwin, CA 94508-9646
Phone Number: 1-707-965-6231
SUMMARY OF BENEFITS AND COVERAGE
Benefit Summary for July 1, 2012 – June 30, 2013
Pacific Union College is proud to offer a wide range of benefits to meet the needs of you and your family. Enclosed in
this summary are highlights of the following:
Please note that this is a summary of the benefits as covered under the health care assistance plan are effective July 1,
2011 – June 30, 2012. This bulletin should answer most of your questions about the plan. However, this bulletin does not
fully describe all of the benefits of the PUC health plan, limitations and exclusions. For more specific details or to obtain
further information, contact your plan administrator – PUC Human Resources Ext. 6231 to examine the current Plan
document or visit the PUC website at www.puc.edu to download a copy of the entire Health Care Assistance Plan
Document.
HEALTH CARE REFORM
Effective July 1, 2011, the Health Care Assistance Plan for Employees of Pacific Union College has changed their
benefit plan to comply with Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act
of 2010. Below is an outline of the changes:
1. Coverage for children up to age 26, regardless of student status, marital status, financial dependency or residency.
Note: Coverage is not available for your adult child’s spouse or children (i.e., grandchildren).
2. There are no pre-existing conditions limitations for any individuals (employees or children) under age 19.
3. There is no longer lifetime limits on Essential Benefits (as defined in Section 1302(b) of the Affordable Care Act):
ambulatory care, emergency care, hospitalization, maternity/newborn care, mental health and substance abuse use
disorder services, prescription drugs, rehabilitation services, lab services, preventive/wellness care, chronic disease
management, and pediatric care*, including oral and vision care. *Note: Awaiting regulatory guidance on what needs to be
included for oral and vision care, as well as clarification on what the age limit is for pediatric care). The plan has however,
designated Non-Essential Health Benefits; based on a good faith effort to comply and a reasonable interpretation of the
term “essential health benefits.” These non-essential health benefits include infertility treatment, orthodontic treatment and
refractive eye surgery.
4. Plan cover 100% of the cost of in-network preventive care; out-of-network providers may be used for this care, but a
coinsurance amount and deductible will be applied
5. No recession of coverage unless a 30-day prior notice has been provided to participants (except in the case of fraud of
misrepresentation). Note: Termination of benefits due to non-payment of premiums is not considered to be rescission.
6. Access to designate any PCP (including pediatrician and OB/GYN) without the need for a referral or prior authorization.
7. Requirements or limitations on benefits for out-of-network emergency services cannot be more restrictive than the
requirements or limitations that apply to in-network emergency services.
8. An Independent Review Organization will review claims on a second appeal. Note: This has been, and will continue to
be, Delta Health Systems’ practice.
9. Under the Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education
Reconciliation Act, this non-grandfathered plan is required to provide a process for an external review of claims that have
received an adverse benefit determination. The external review includes a process for a standard external review and a
process for an expedited external review.
PUC is in the process of incorporating all of these changes into a new Summary Plan Description that will be available in
the near future, in the meantime, attached is a summary for the upcoming benefit year. Page 2 of 8
Benefit Summary for July 1, 2012 – June 30, 2013
ELIGIBILITY
You are eligible to participate in the Health Care Assistance Plan if you are:
 curre ntly e m ploye d on a full-time basis and
 ha ve com ple te d your be ne fits wa iting pe riod.
Your spouse and dependent children may be covered by the Plan if they meet the eligibility requirements. However, no
one can be covered at the same time both as an employee and dependent.
MEDICAL PLAN BENEFITS
Preferred Provider Organization (PPO)
A PPO plan allows you to receive medical care and services from any physician or facility you choose. As a PPO plan
participant, you do not need to select a primary care physician, nor do you need referrals for a specialist. There are two
types of providers:
In-network Providers: Including physicians and hospitals, which have agreed to become part of the organization and
provide care to members at a lower negotiated rate. If you use in-network providers, benefit coverage will be greater and
your out-of-pocket expenses will be lower.
Out-of-network Providers: Any provider not affiliated with the network is out-of-network. If you reside in a PPO area,
but you elect not to participate in the Participating Provider Program your covered benefits will be reduced in the following
ways:
You will be reimbursed only 50% of the amounts listed in the charts, and
Any costs associated with out-of-network medical care do not apply towards reducing your out-of-pocket maximum.
PLAN BENEFITS: DESIGNATED PROVIDER PROGRAM
IMPORTANT: The following limits are based on a JULY 1 – JUNE 30 Plan Year.
Lifetime Maximum
No lifetime maximum
Plan Year Deductible
 $350/Em ploye e O nly
 $700/Fa m ily
Important: Only Office Visits are exempt from the
Deductible
Plan Year Out-of-Pocket Maximum (OOP)
 $3,000/Em plo ye e O nly
 $6,000/Fa m ily
Important: Out-of-Pocket Maximum (OOP) applies to all
medical claims except where noted
Plan Year Cost Contribution
 $50.00/Em plo ye e O nly
 $80.00/Em plo ye e + 1 De pe nde nt
 $110.00 Em ploye e + 2 or More De pe nde nts
WOMEN’S HEALTH & CANCER RIGHTS ACT (WHCRA)
Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for
mastectomy-related services including all stages of reconstruction and surgery to achieve symmetry between the
breasts, prostheses and complications resulting from a mastectomy, including lymphedemas?
Contact your Human Resources Department for more information.
HIPAA NOTICE OF SPECIAL ENROLLMENT
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health
insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or
your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your
dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’
other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may
be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the
marriage, birth, adoption, or placement for adoption.
Also, you may be entitled to special enrollment rights pursuant to the Children’s Health Insurance Program
Reauthorization Act of 2009 (the Act) if you or your dependents:
1. Lose coverage under a Medicaid or State Plan (such as California’s Medi-Cal); or
2. Become eligible for group health premium assistance under a Medicaid plan or State Plan.
If a special enrollment right is provided pursuant to the Act, you may change your election consistent with such
special enrollment right within 60 days as long as the election is made consistent with the special enrollment.
Waiver of Coverage
If you elect to waive coverage for yourself or your dependents (including your spouse), you acknowledge that you and
your spouse and/or dependent child(ren) can only enroll later during an annual open enrollment period. An exception
to this is if you and your spouse and/or dependent child(ren) are entitled to enroll in accordance with the “Special
Enrollment Rights” described above.
To request special enrollment or obtain more information, contact your Human Resources Department.
HIPAA NOTICE OF AVAILABILITY OF PRIVACY PRACTICES
The PACIFIC UNION COLLEGE HEALTH PLAN (Plan) maintains a Notice of Privacy Practices that provides information to
individuals whose protected health information (PHI) will be used or maintained by the Plan. If you would like a copy
of the Plan's Notice of Privacy Practices, please contact Galyn Bowers, Director of Human Resources, Pacific Union
College, Financial Administration, One Angwin Avenue, Angwin, CA 94508-9646, 1-707-965-6231. The Notice
describes the legal obligations of the PACIFIC UNION COLLEGE HEALTH PLAN (the “Plan”) and your legal rights
regarding your protected health information held by the Plan under the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). Among other things, the Notice describes how your protected health information may be used or
disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or
required by law.
NOTICE OF PRIVACY PRACTICES
THE PACIFIC UNION COLLEGE HEALTH PLAN HIPAA PRIVACY NOTICE
Effective as of July 1, 2012
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Federal law requires the PACIFIC UNION COLLEGE HEALTH PLAN (the “Plan”) to protect the privacy of your health
information, provide this notice describing the Plan’s health information practices and to follow its terms. The Plan
may change this notice at any time. If this notice is revised, the Plan will provide a revised notice by mail and will
post the notice on http://www.puc.edu/campus-services/human-resources/forms-policies. To obtain a paper copy of
this notice contact the Plan’s Privacy Officer Galyn Bowers, Director of Human Resources, Pacific Union College,
Financial Administration, One Angwin Avenue, Angwin, CA 94508-9646, 1-707-965-6231.
This Notice describes the legal obligations of the PACIFIC UNION COLLEGE HEALTH PLAN (the “Plan”) and your legal
rights regarding your protected health information held by the Plan under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). Among other things, this Notice describes how your protected health information
may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that
are permitted or required by law. We are required to provide this Notice of Privacy Practices (the “Notice”) to you
pursuant to HIPAA.
The HIPAA Privacy Rule protects only certain medical information known as “protected health information.” Generally,
protected health information is individually identifiable health information, including demographic information or
genetic information, collected from you or created or received by a health care provider, a health care clearinghouse,
a health plan, or your employer on behalf of a group health plan, that relates to:
(1) your past, present or future physical or mental health or condition;
(2) the provision of health care to you; or
(3) the past, present or future payment for the provision of health care to you.
Effective Date
This Notice is effective July 1, 2012.
Our Responsibilities
We are required by law to:
•
maintain the privacy of your protected health information;
•
provide you with certain rights with respect to your protected health information;
•
provide you with a copy of this Notice of our legal duties and privacy practices with respect to your protected
health information; and
•
follow the terms of the Notice that are currently in effect.
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health
information that we maintain, as allowed or required by law. If we make any material change to this Notice, we will
provide you with a copy of our revised Notice of Privacy Practices by [describe how Plan will provide individuals with a
revised notice—e.g., by mail to their last-known address on file].
USE & DISCLOSURE FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS
The Plan may use or disclose your health information in order to provide you with treatment, to arrange for payment
and for health care operations. It may share your health information with its business associates (service providers),
your employer and with health care entities involved with providing you health benefits and it may disclose
information to comply with certain laws.
USE & DISCLOSURE WITH YOUR WRITTEN PERMISSION
All other uses or disclosures of your health information will be made only with your written permission. Once you give
written permission for a use or disclosure, HIPAA will not protect this information and it may be re-disclosed. You
may revoke any permission that you have given the Plan at any time in writing, but the Plan and other parties have a
right to rely on your written permission until they receive written notice of your revocation.
YOUR RIGHTS TO YOUR HEALTH RECORDS
You have a right to access, inspect, copy and amend your health records maintained by the Plan. You also have a
right to receive an accounting of non-routine disclosures of your health information and to request additional
restrictions on the Plan’s communication with you and on the use and disclosure of your health information. To
exercise these rights with respect to the PACIFIC UNION COLLEGE HEALTH PLAN, you should contact Galyn Bowers,
Director of Human Resources, Pacific Union College, Financial Administration, One Angwin Avenue, Angwin, CA 945089646, 1-707-965-6231.
IF YOU BELIEVE YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED, you may file a written complaint with the
Plan’s Privacy Officer or with the Secretary of the Department of Health and Human Services. You may request a
copy of the Plan’s complaint procedure. The Plan will not retaliate against you for filing a complaint.
1.
Statement of the Plan Duties
The Plan understands that medical information about you and your health is personal and the Plan is committed to
protecting health information. The Plan creates a record of health care claims reimbursed under the Plan for Plan
administration purposes. This notice applies to all of the medical records maintained by the Plan. Your personal
physician or health care provider may have different policies or notices regarding the physician’s use and disclosure of
medical information created in the doctor’s office or clinic.
The Plan does not sell information about you. The Plan does not share your information with anyone else for
marketing purposes. Your health information is only used to administer the Plan. If the Plan determines that your
Unsecured PHI has been, or is reasonably believed by the Covered Entity to have been, accessed, acquired, used, or
disclosed as a result of a breach of HIPAA privacy or security, the Plan will provide notice of and information regarding
the breach, generally within 60 days.
2.
Permissible Uses and Disclosures of Protected Health Information
This section describes when and how your personal health information can be used:
For Treatment: The Plan may use and disclose your health information without your permission to facilitate
treatment or services by providers. The Plan may disclose health information about you to providers, including
doctors, nurses, technicians, medical students, pharmacists or other hospital personnel who are involved in your care.
For example, the Plan may provide your health information to a pharmacist to determine if a pending prescription
would interfere with other prescriptions.
For Payment: The Plan may use and disclose your health information without your permission to:
•
Determine eligibility for Plan benefits;
•
Determine treatment coverage;
•
Reimburse you for the provision of health care;
•
Facilitate payment for the treatment and services you received from health care providers, including claim
submission for stop-loss insurance;
•
Determine benefit responsibility under the Plan; or
•
Coordinate Plan coverage with other applicable insurance coverage(s).
For example, the Plan may share your health information with your health care provider when determining treatment
coverage under the Plan. The Plan may share health information with a utilization review or pre-certification service
provider. The Plan may share medical information with another entity to assist with the adjudication or subrogation of
health claims or with another health plan to coordinate benefit payments.
For Health Care Operations: The Plan may use and disclose your health information without your permission for
Plan operations necessary to run the Plan. The Plan may use health information in connection with:
•
Conducting quality assessment and improvement activities;
•
Underwriting;
•
Premium rating;
•
Claim submission for stop-loss (or excess loss) insurance or reinsurance;
•
Amending, replacing or adding benefits;
•
Conducting or arranging for medical review, legal services, audit services, fraud and abuse detection programs; or
•
General Plan administrative activities such as business planning, development, and cost management.
For example, the Plan may submit your health information to external auditors or agencies to assess the quality of a
health plan. The Plan may also submit your health information to a stop-loss insurance carrier or to obtain pricing
information.
Health Plan Sponsor: Health information will generally not be disclosed to your employer except information
regarding enrollment in the Plan or enrollment in a specific benefit, such as the medical flexible spending account.
Summary health information may be used to shop for insurance or amend the Plan, but identifying information, such
as your name or social security number, will not be included. Although the Plan does not anticipate giving any other
health information to your employer, if your employer needs information to administer the Plan, certain specified
individuals known as privacy employees will be able to obtain the minimum amount of information needed to allow
your employer to perform its administrative function. These privacy employees will not receive any protected health
information unless:
•
the Plan document specifically allows them to receive this information,
•
your Employer certifies to follow Plan document provisions that protect the information, and
•
the privacy employees receive training to ensure that they will protect the information as required by HIPAA.
For Remuneration: Health information may generally not be sold for the direct or indirect receipt of remuneration
without an authorization from you (which must also specify whether the information can be further exchanged for
remuneration by the entity initially receiving the data).
Effective February 18, 2010, the Plan must obtain your authorization if it will be paid by an outside entity to send a
communication to you unless the payment is a reasonable amount for communications that describe a drug or biologic
that is currently being prescribed for or administered to you. This rule does not apply to payments for treatment.
Additionally, effective February 18, 2010, you may opt-out of receiving fund raising communications based on
demographic information maintained by the Plan. To opt-out, follow the instructions on the last piece of information
received after February 18, 2010 or contact the Privacy Officer for instructions.
Effective six months after issuance of Final Regulations in 2010, there will be several exceptions to this limitation,
which will allow the sale of health information for the following purposes:
•
For public health activities described in the Privacy Rule;
•
For research (as described in the Privacy Rule), as long as the price charged reflects the costs of preparation and
transmittal of the data;
•
For treatment of the individual, subject to any regulations the Secretary may promulgate to prevent inappropriate
use of the data;
•
When the covered entity is being sold, transferred, merged or consolidated (in whole or in part) with another
covered entity (or an entity that will become a covered entity after the transaction), and any due diligence
associated therewith;
•
When the remuneration is provided by a covered entity to a business associate for activities that the business
associate is undertaking on behalf of and at the specific request of the covered entity;
•
To provide an individual with a copy of his or her protected health information;
•
Any other exception determined by the Secretary in regulation to be similarly necessary and appropriate as the
foregoing exceptions.
Third Party Disclosure: Information may be disclosed to other entities that provide business services to the Plan
related to transactions with you, such as plan administration, claim processing, or audit services. Examples of third
parties include medical insurers, third party administrators, consultants and reinsurance companies. Prior to
disclosure, these entities must agree to maintain the privacy of your health information.
Organized Health Care Arrangement: The Plan may share health information as part of an organized health care
arrangement to service your health-related business transactions. All health benefits, including medical, dental and
vision, are considered to be a part of the Plan. The Plan may share information with health insurance issuers, HMOs,
or network providers as necessary to carry out treatment, payments, or health care operations among these entities.
The Plan may also share information as necessary with operational units to provide administrative services, policy
documentation, preparation and delivery, and claim processing.
3.
Additional Permissible Uses and Disclosures of Protected Health Information
As Required By Law: The Plan may use and disclose your health information without your permission when required
to do so by federal, state, or local law. For example, the Plan may disclose your health information in response to a
court order.
Avert a Serious Threat to Health or Safety: The Plan may use and disclose health information about you when
necessary to prevent a serious threat to your health and safety or the health and safety of the public or another
person.
Coroners, Medical Examiners, and Funeral Directors: The Plan may disclose health information to a coroner,
medical examiner, or funeral director. This may be necessary to identify a deceased person or determine a cause of
death.
Health Oversight Agencies: The Plan may disclose health information to a health oversight agency for activities
authorized by law.
Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, the Plan
may disclose health information about you to the correctional institution or law enforcement official.
Law Enforcement: The Plan may disclose health information if asked to do so by law enforcement official(s):
•
In response to a court order, subpoena, warrant, summons, or similar process;
•
To identify or locate a suspect, fugitive, material witness, or missing person;
•
Regarding the victim of a crime, if under certain limited circumstances, the Plan is unable to obtain the victim’s
agreement;
•
Regarding a death that may be the result of criminal conduct;
•
In emergency circumstances to report a crime, its location, the victim’s or perpetrator’s location, or the
perpetrator’s identity or description.
Lawsuits and Disputes: The Plan may disclose health information about you in response to a court or administrative
order. The Plan may disclose health information about you in response to a subpoena, discovery request, or other
lawful process by someone else involved in the dispute, but only after efforts have been made to tell you about the
request or to obtain an order protecting the requested information.
Military: If you are a member of the armed forces, the Plan may release health information about you as required by
military command authorities.
National Security and Intelligence Activities: The Plan may disclose health information about you to authorized
federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Organ and Tissue Donation: If you are an organ donor, the Plan may release health information to organizations
that handle organ procurement, transplantation, or organ donation bank to facilitate organ or tissue donation and
transplantations.
Public Health Risks: The Plan may disclose health information about you for public health activities such as:
•
Preventing or controlling disease, injury, or disability;
•
Reporting births or deaths;
•
Reporting child abuse or neglect;
•
Reporting reactions to medications or problems with products;
•
Notifying people of recalls of products;
•
Notifying people who may have been exposed to a disease or may be at risk for contracting or spreading a disease
or condition;
•
Notifying the appropriate government authority if the Plan believes a patient has been the victim of abuse,
neglect, or domestic violence. This disclosure will only be made if you agree or when required or as authorized by
law.
Workers’ Compensation: The Plan may release health information about you to the extent necessary to comply with
laws relating to workers’ compensation or similar no-fault programs.
Purposes To Which You Have Not Objected: In limited circumstances, the Plan may use or disclose your protected
health information after you have been given an opportunity to object and you have not objected. For example, if you
do not object, the Plan may use limited information about you to notify family members or any other person identified
by you regarding issues directly related to such person’s involvement with your care or payment for that care, or in
emergency circumstances.
4.
Your Rights Regarding Protected Health Information
In addition to your right to know how the Plan may use and disclose your health information, you have the following
rights:
Right to Access, Inspect and Copy: You have the right to access, inspect and copy health information that may be
used to make decisions about your Plan benefits. To request a copy of your health information, submit a written
request to the appropriate contact person identified on the first page of this notice. A fee may be charged for the
copying, mailing, or other administrative costs associated with your request. Effective February 18, 2010, any
electronic health records must be transmitted directly to you in electronic form at your clear, conspicuous and specific
directive. Any fee charged for the electronic record will not be greater than our labor costs in responding to the
request.
Right to Amend: As long as the Plan keeps health information that may be used to make decisions about your Plan
benefits, you have the right to request an amendment of incorrect or incomplete health information about you. To
request an amendment, submit a request form and documentation supporting your request to the appropriate contact
person identified on the first page of this notice. The Plan may deny your request if it is not in writing, does not
include support for the request, or requests to amend information that is accurate and complete or was not created by
the Plan (unless the creating entity is no longer available to make the amendment).
Right to an Accounting of Disclosures: You have the right to request an accounting of your health information
disclosures made for purposes other than activities related to treatment, payment, or other health care operations
made by the Plan or its business associates. The accounting of disclosures will generally also not include:
•
disclosures to individuals regarding their own PHI;
•
disclosures incident to an otherwise permitted use or disclosure;
•
disclosures pursuant to an authorization;
•
disclosures for purposes of creation of a facility directory to persons involved in the patient’s care or other
notification purposes;
•
disclosures for specific national security or intelligence purposes;
•
disclosures to correctional institutions or law enforcement when the disclosure was permitted without
authorization;
•
disclosures made as part of a limited data set.
However, if you are requesting an accounting for disclosure of electronic health records after January 1, 2014 for
treatment, payment and health care operations, you may receive an accounting for such disclosure that covers the
previous three years. If a business associate disclosed that information, the Plan may give you information regarding
the business associates involved in disclosing protected health information from their records (and contact
information) and direct you to request an accounting directly from the business associate.
To request an accounting of disclosures, submit a request in writing to the appropriate contact person identified on
the first page of this notice. Your request must state a time period of six years or less, beginning after April 2003. If
you request more than one accounting in a 12-month period, you may be notified that a charge will apply. You may
choose to withdraw or modify your request prior to incurring costs.
Right to Request Restrictions: You have the right to request a restriction or limitation on the health information the
Plan uses or discloses about you for treatment, payment, or health care operations. You also have the right to request
a limit on the health information the Plan discloses about you to someone who is involved in your care or the payment
for your care, such as a family member, but the Plan is not required to comply with your request. Effective February
18, 2010, a plan or a provider must honor your request to restrict disclosure of protected health information to a
health plan for purposes of payment or health care operations if the information pertains solely to a health care item
or services that the individual has paid for in full out-of-pocket.
To request restrictions by the Plan, deliver your written request to the appropriate contact person identified on the
first page of this notice detailing the information you want to limit; to whom the limit would apply; and whether you
want the limit to apply to the Plan’s use, disclosure, or both.
Right to Request Confidential Communications: If disclosure (all or in part) could endanger you, you have the
right to request that the Plan communicate with you about health matters in a specific way or location. For example,
you may request that the Plan only contact you at work or by mail.
To request confidential communications, you must submit your request in writing to the appropriate contact person
identified on the first page of this notice. You are not required to provide a reason for your request. The Plan will
accommodate all reasonable requests. Your request must specify how or where you would prefer to be contacted.
5.
Changes to This Notice
The Plan reserves the right to change this notice effective for current health information as well as any information
received in the future.
6.
Practices Regarding Confidentiality
The Plan restricts access to health information about you to those who need the information in order to provide
products or services to you. The Plan maintains physical, electronic, and procedural safeguards to comply with federal
regulations to guard health information.
MEDICAID AND THE CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP)
OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND FAMILIES
If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have
premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP
programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their
health premiums.
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, you can contact your State Medicaid or CHIP office or dial
1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a
program that might help you pay the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your
employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your
dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment”
opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.
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, 2012. You should contact your
State for further information on eligibility –
ALABAMA – Medicaid
COLORADO – Medicaid
Website: http://www.medicaid.alabama.gov
Medicaid Website: http://www.colorado.gov/
Phone: 1-855-692-5447
Medicaid Phone (In state): 1-800-866-3513
ALASKA – Medicaid
Medicaid Phone (Out of state): 1-800-221-3943
Website:
http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA – CHIP
FLORIDA – Medicaid
Website: http://www.azahcccs.gov/applicants
Website: https://www.flmedicaidtplrecovery.com/
Phone (Outside of Maricopa County): 1-877-764-5437
Phone (Maricopa County): 602-417-5437
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid
Phone: 1-800-869-1150
IDAHO – Medicaid and CHIP
Medicaid Website:
www.accesstohealthinsurance.idaho.gov
Medicaid Phone: 1-800-926-2588
CHIP Website: www.medicaid.idaho.gov
MONTANA – Medicaid
Website: http://medicaidprovider.hhs.mt.gov/PACIFIC
UNION COLLEGEpages/
PACIFIC UNION COLLEGEindex.shtml
Phone: 1-800-694-3084
CHIP Phone: 1-800-926-2588
INDIANA – Medicaid
NEBRASKA – Medicaid
Website: http://www.in.gov/fssa
Website:
http://dhhs.ne.gov/medicaid/Pages/med_kidsconx.aspx
Phone: 1-800-889-9948
Phone: 1-877-255-3092
IOWA – Medicaid
NEVADA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562
Medicaid Phone: 1-800-992-0900
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid
NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Website: www.dhhs.nh.gov/ombp/index.htm
Phone: 1-800-635-2570
Phone: 603-271-5218
LOUISIANA – Medicaid
NEW JERSEY – Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/PACIFIC UNION COLLEGEs/medicaid/
MAINE – Medicaid
Medicaid Phone: 1-800-356-1561
Website: http://www.maine.gov/dhhs/OIAS/publicassistance/index.html
CHIP Website: http://www.njfamilycare.org/index.html
Phone: 1-800-572-3839
CHIP Phone: 1-800-701-0710
MASSACHUSETTS – Medicaid and CHIP
NEW YORK – Medicaid
Website: http://www.mass.gov/MassHealth
Website:
http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-462-1120
Phone: 1-800-541-2831
MINNESOTA – Medicaid
NORTH CAROLINA – Medicaid and CHIP
Website: http://www.dhs.state.mn.us/
Click on Health Care, then Medical Assistance
Website: http://www.ncdhhs.gov/dma
Phone: 1-800-657-3629
Phone: 919-855-4100
MISSOURI – Medicaid
NORTH DAKOTA – Medicaid
Website:
http://www.dss.mo.gov/mhd/participants/pages/
hipp.htm
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 573-751-2005
Phone: 1-800-755-2604
OKLAHOMA – Medicaid and CHIP
UTAH – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Website: http://health.utah.gov/upp
Phone: 1-888-365-3742
Phone: 1-866-435-7414
OREGON – Medicaid and CHIP
VERMONT– Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Website: http://www.greenmountaincare.org/
Phone: 1-877-314-5678
Phone: 1-800-250-8427
PENNSYLVANIA – Medicaid
VIRGINIA – Medicaid and CHIP
Website: http://www.dpw.state.pa.us/hipp
Medicaid Website: http://www.dmas.virginia.gov/rcpHIPP.htm
Phone: 1-800-692-7462
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND – Medicaid
WASHINGTON – Medicaid
Website: www.ohhs.ri.gov
Website:
http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 401-462-5300
Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA – Medicaid
WEST VIRGINIA – Medicaid
Website: http://www.scdhhs.gov
Website: www.dhhr.wv.gov/bms/
Phone: 1-888-549-0820
Phone: 1-877-598-5820, HMS Third Party Liability
SOUTH DAKOTA - Medicaid
WISCONSIN – Medicaid
Website: http://dss.sd.gov
Website: http://www.badgercareplus.org/pubs/p10095.htm
Phone: 1-888-828-0059
Phone: 1-800-362-3002
TEXAS – Medicaid
WYOMING – Medicaid
Website: https://www.gethipptexas.com/
Website:
http://health.wyo.gov/healthcarefin/equalitycare
Phone: 1-800-440-0493
Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2012, 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
1-866-444-EBSA (3272)
OMB Control Number 1210-0137 (expires 09/30/2013)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
1-877-267-2323, Ext. 61565
GENERAL NOTICE OF PRE-EXISTING CONDITION EXCLUSION
This plan imposes a pre-existing condition exclusion for employees as well as dependents over the age of 18. This
means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time
before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical
advice, diagnosis, care, or treatment was recommended or received within a six-month period. Generally, this sixmonth period ends the day before your coverage becomes effective. However, if you were in a waiting period for
coverage, the six-month period ends on the day before the waiting period begins. The pre-existing condition
exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 30 days after birth, adoption, or
placement for adoption.
This exclusion may last up to 12 months (18 months if you are a late enrollee) from your first day of coverage, or, if
you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this
exclusion period by the number of days of your prior “creditable coverage.” Most prior health coverage is creditable
coverage and can be used to reduce the pre-existing condition exclusion if you have not experienced a break in
coverage of at least 63 days. To reduce the 12-month (or 18-month) exclusion period by your creditable coverage,
you should give us a copy of any certificates of creditable coverage (HIPAA Certificates) you have. If you do not have
a certificate, but you do have prior health coverage, we will help you obtain one from your prior plan or issuer. There
are also other ways that you can show you have creditable coverage. Please contact us if you need help
demonstrating creditable coverage.
Each HIPAA Certificate (or other evidence of creditable coverage) will be reviewed by the Plan Administrator (with the
assistance of the prior plan administrator or insurer) to determine its authenticity. Submission of a fraudulent HIPAA
Certificate would be considered a federal health care crime under HIPAA and may be punishable by fine and/or
imprisonment.
All questions about the pre-existing condition exclusion and creditable coverage should be directed to Human
Resources.
IRS RULES FOR QUALIFYING CHILD OR QUALIFYING RELATIVE
IRS RULES FOR DEPENDENT/QUALIFYING CHILDREN AND QUALIFYING RELATIVE
IRS Publication 501 describes who is a tax dependent for federal tax exemption purposes and the definition of
dependent described in Publication 501 for purposes of the federal exemption also applies to federal taxation of
certain benefit and health coverage, with the following modifications:
1. For benefits purposes, a dependent may be treated as having dependents of his or her own and still be a
dependent.
2. For benefits purposes, a dependent may file a joint return with someone else and still be my dependent.
3. For benefits purposes, a dependent may have gross income that is greater than or equal to the exemption
amount defined under Internal Revenue Code Section 151(d) and still be my dependent.
In this form, we have summarized the rules as they relate to your benefit plans, but the information provided should
not be construed as legal or tax advice. The contents are intended for general information purposes only and you are
urged to consult an attorney or tax advisor concerning your own situation and any specific questions you may
have. The rules define two types of dependents, "Qualifying Children" and "Qualifying Relatives." Generally:


a “Qualifying Child” is your child, or a brother, sister, stepbrother, stepsister or descendant of any such
relative who lives with you for over half of the year, does not provide over half of his/her own support and is
under age 19 as of the close of the calendar year (or under age 24 as of the close of the calendar year and a
full-time student) or is permanently and totally disabled. If a person is a "Qualifying Child" of one taxpayer,
the person cannot be a "Qualifying Relative" of another.
a "Qualifying Relative" is a person that doesn’t meet the definition of a “Qualifying Child” for any taxpayer,
receives more than half of his/her support from you, and is either your relative (generally a relative will
include your parent, grandparent, stepparent, child, grandchild, brother, sister, stepbrother, stepsister, aunt
or uncle, niece or nephew, or your spouse’s parents, brother, sister or children) or an individual that has the
same principle place of abode as you and is a member of your household for the entire taxable year
More recently, federal law clarified the treatment of certain tax dependents.

Fostering Connections to Success and Increasing Adoptions Act of 2008 requires that a “qualifying child” be
unmarried and younger than the individual claiming the child as a dependent and requires that a non-parent
have a higher adjusted gross income than either of the parents to claim the child as a dependent.
Rev. Proc. 2008-48 allows children of divorced parents to be covered by either parent’s employee benefit plan on a
tax-preferred basis.
These changes may impact your family's entitlement to employee benefits, may change the tax treatment for some
benefit coverage, and may eliminate reimbursement of expenses under a healthcare flexible spending account. The
rule also does not allow you to receive dependent care reimbursement for a child under 13 years of age or an
individual who is incapable of self-care unless that that child or individual is either your Qualifying Child or Qualifying
Relative.
If your dependent child does not meet the definition of Qualifying Child or Qualifying Relative, the portion paid by the
employer and the portion paid by the employee on a pre-tax-basis will result in imputed income to you based on the
Fair Market Value of the coverage.