Important Legislative Notices
WOMEN’S HEALTH CANCER RIGHTS ACT (WHCRA)
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomyrelated benefits, coverage will be provided in a manner determined in consultation with attending
physician and the patient, for:
 All stages of reconstruction of 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 will be provided subject to the same deductibles and coinsurance applicable to other
medical and surgical benefits provided under this plan. If you would like more information on WHCRA
benefits, call your plan administrator at 855-858-3740.
HIPAA AND MEDICAID/SCHIP SPECIAL ENROLLMENT RIGHTS NOTICE
Loss of other coverage: If you decline enrollment for yourself or for an eligible dependent (including
your spouse) while other health insurance or group health plan coverage is in effect, 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 towards the other coverage).
Loss of Medicaid or SCHIP 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 is in effect, you may be able to enroll yourself and your dependents in this
plan 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.
New dependent: 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 new dependents. However, you must
request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
Eligibility for Medicaid or SCHIP premium assistance: If you or your dependents (including your
spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state
children's health insurance program with respect to coverage under this plan, you may be able to
enroll yourself and your dependents in this plan. However, you must request enrollment within 60
days after your or your dependents’ determination of eligibility for such assistance.
MEDICARE PART D
Note: you will receive the Medicare Creditable coverage notice of prescription benefits, indicating that
the PPO plans and the Choice Care Plans are creditable. If you or your dependents are Medicare
eligible and you did not receive this form or if you have further questions, please contact your HR
representative.
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 are eligible for health coverage from your
employer, your State may have a premium assistance program that can help pay for coverage. These States
use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also
have access to health insurance through their employer. If you or your children are not eligible for Medicaid or
CHIP, you will not be eligible for these premium assistance programs.
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, as well as eligible under your employer plan, your employer must permit you to enroll in your employer
plan if you are not 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, you can contact the Department of Labor electronically at
www.askebsa.dol.gov or by calling toll-free 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, 2013. You should contact your State for
further information on eligibility –
ALABAMA – Medicaid
COLORADO – Medicaid
Website: http://www.medicaid.alabama.gov
Phone: 1-855-692-5447
Medicaid Website: http://www.colorado.gov/
Medicaid Phone (In state): 1-800-866-3513
Medicaid Phone (Out of state): 1-800-221-3943
ALASKA – Medicaid
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
Phone (Outside of Maricopa County): 1-877-764-5437
Phone (Maricopa County): 602-417-5437
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
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IDAHO – Medicaid and CHIP
MONTANA – Medicaid
Medicaid Website:
www.accesstohealthinsurance.idaho.gov
Website:
http://medicaidprovider.hhs.mt.gov/clientpages/
clientindex.shtml
Medicaid Phone: 1-800-926-2588
Phone: 1-800-694-3084
CHIP Website: www.medicaid.idaho.gov
CHIP Phone: 1-800-926-2588
INDIANA – Medicaid
NEBRASKA – Medicaid
Website: http://www.in.gov/fssa
Website: www.ACCESSNebraska.ne.gov
Phone: 1-800-889-9949
IOWA – Medicaid
Phone: 1-800-383-4278
NEVADA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Medicaid Website: http://dwss.nv.gov/
Phone: 1-888-346-9562
KANSAS – Medicaid
Medicaid Phone: 1-800-992-0900
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:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 1-800-635-2570
Phone: 603-271-5218
NEW JERSEY – Medicaid and CHIP
LOUISIANA – Medicaid
Website: http://www.lahipp.dhh.louisiana.gov
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Phone: 1-888-695-2447
MAINE – Medicaid
Medicaid Phone: 609-631-2392
Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
Phone: 1-800-977-6740
TTY 1-800-977-6741
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
NORTH CAROLINA – Medicaid
MINNESOTA – Medicaid
Website: http://www.dhs.state.mn.us/
Click on Health Care, then Medical Assistance
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
Phone: 1-800-657-3629
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
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OKLAHOMA – Medicaid and CHIP
UTAH – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Website: http://health.utah.gov/upp
Phone: 1-888-365-3742
OREGON – Medicaid and CHIP
Phone: 1-866-435-7414
VERMONT– Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid
VIRGINIA – Medicaid and CHIP
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
Medicaid Website: http://www.dmas.virginia.gov/rcpHIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
WASHINGTON – Medicaid
RHODE ISLAND – Medicaid
Website: www.ohhs.ri.gov
Phone: 401-462-5300
Website:
http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
SOUTH CAROLINA – Medicaid
Phone: 1-800-562-3022 ext. 15473
WEST VIRGINIA – Medicaid
Website: http://www.scdhhs.gov
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
WISCONSIN – Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website: http://www.badgercareplus.org/pubs/p10095.htm
TEXAS – Medicaid
Phone: 1-800-362-3002
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 July 31, 2013, 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)
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
OMB Control Number 1210-0137 (expires 09/30/2013)
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HIPAA Privacy Notice
This notice describes how medical information about you may be used and disclosed and
how you can obtain access to this information. Please review it carefully.
The following information is effective as of September 1, 2013.
The Day & Zimmermann Flexible Benefits Plan (“The Plan”) is required by law to take reasonable steps to
ensure the privacy of your personally identifiable health information and to inform you about the following:




The Plan’s use and disclosure of Protected Health Information (“PHI”);
Your privacy rights with respect to your PHI;
Your right to file a complaint with the Plan and to the Secretary of the US Department of Health and Human
Services; and
The person or office to contact for further information about the Plan’s privacy practices.
The term Protected Health Information (“PHI”) includes all individually identifiable health information transmitted
or maintained by the Plan, regardless of form (oral, written, electronic). Please note that Day & Zimmermann
makes every effort to minimize the receipt of PHI.
Section 1 – Notice of PHI Uses and Disclosures
Required PHI Uses And Disclosures
Upon your request, the Plan is required to give you access to certain PHI in order for you to inspect and copy it.
Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human
Services to investigate or determine the Plan’s compliance with the privacy regulations.
Uses and disclosures for which consent, authorization or opportunity to object is not required
The Plan will use PHI without your authorization for purposes exclusively related to payment and health care
operations, where required by law or in certain other limited situations as outlined below. The Plan will also
disclose PHI to the Day & Zimmermann Group, Inc., the Plan Sponsor, for purposes related to payment and
health care operations.
The following categories describe the different ways in which the plan may use and disclose your PHI without
your consent or authorization. Please note that every permitted use or disclosure of your PHI is not listed
below. However, the different ways the Plan will, or might, use or disclose your PHI do fall within one of the
permitted categories described below.
Payment: The Plan may use and disclose your PHI for all payment activities including, but not limited to,
actions to make coverage determinations and payment (including billing, claims management, subrogation, plan
reimbursement, reviews for medical necessity and appropriateness of care and utilization review and
preauthorization).
Health Care Operations: The Plan may use and disclose your PHI to conduct and support business and
management activities including, but are not limited to, quality assessment and improvement, underwriting,
developing premium rates, and other insurance activities relating to creating or renewing insurance contracts. It
also includes conducting or arranging for medical review, legal services and auditing functions including fraud
and abuse compliance programs, business planning and development, business management and general
administrative activities. However, we will not use your genetic information for underwriting purposes.
Required by Law: The Plan may disclose your PHI when required to do so by law. For example, the law
requires the plan to disclose your PHI:
 When required by the Secretary of the U.S. Department of Health and Human Services to investigate the
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
plan compliance efforts; and
To health oversight agencies, to allow them to conduct audits and investigations of the health care system,
to determine eligibility for government programs, to determine compliance with government program
standards, and for certain civil rights enforcement actions.
Public Health Activities: The Plan may disclose your PHI to public health agencies for public health activities
that are permitted or required by law, such as to:
 prevent or control disease, injury or disability;
 maintain vital records, such as births and deaths;
 notify individuals if a product or device they may be using has been recalled; and
 notify a person about potential exposure to communicable disease
Health Oversight Activities: The Plan may disclose your PHI to a health oversight agency for activities
authorized by law, such as: audits; investigations; inspections; licensure or disciplinary actions; or civil,
administrative, or criminal proceedings or actions. Health Oversight agencies seeking this information include
government agencies that oversee: (i) the health care system; (ii) government benefit programs; (iii) other
government regulatory programs; and (iv) compliance with civil rights laws.
Lawsuits and Other Legal Disputes: The Plan may disclose your PHI in response to a court or administrative
order, subpoena, discovery request, or other lawful process once all administrative requirements of the HIPAA
Privacy Rules have been met.
Law Enforcement: The Plan may disclose your PHI to law enforcement officials under certain conditions. For
example, PHI may be disclosed to permit identification and location of witnesses, victims, and fugitives or in
response to a search warrant or court order.
Coroners, Medical Examiners, or Funeral Directors: The Plan may disclose your PHI to a coroner or medical
examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as
authorized by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, as
necessary to carry out their duties with respect to the decedent.
To Prevent a Serious Threat to Health or Safety: As permitted by law, the Plan may disclose your PHI if the
Plan believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or
safety of a person or the public.
Workers’ Compensation: As part of your workers’ compensation claim, the Plan may need to disclose your
PHI to a worker’s compensation carrier.
Uses and disclosures that require your written authorization
Your written authorization will be obtained before the Plan uses or discloses PHI that is not described above.
You may give us written authorization permitting us to use your PHI or disclose it to anyone for any purpose.
We will obtain your written authorization for uses and disclosures of your PHI that are not identified by this
Notice, or are not otherwise permitted by applicable law. For example, in general and subject to specific
conditions, we will not use or disclose your psychiatric notes; we will not use or disclose your PHI for marketing;
and we will not sell your PHI, unless you give us a written authorization.
Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use
or release
Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if:


The information is directly relevant to the family or friend’s involvement with your care or payment for that
care; and
You have either agreed to the disclosure or have been given an opportunity to object and have not objected.
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Section 2 – Rights of Individuals
Right to request Restrictions on PHI Uses and Disclosures
You may request the Plan restrict uses and disclosures of your PHI to carry out treatment, payment, or health
care operations, or to restrict uses and disclosures to family members, relatives, friends or other persons
identified by you who are involved in your care or payment for your care. However, the Plan is not required to
agree to your request. In addition, you have the right to restrict disclosure of PHI to the health plan for payment
or healthcare operations (but not for carrying out treatment) in situations where you have paid the healthcare
provider out-of-pocket in full. In this case, the Plan is required to implement the restrictions that you request.
The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at
alternative locations. You or your personal representative will be required to complete a form to request
restrictions on uses and disclosures of PHI. Such requests should be made to the Benefits Director.
Right To Inspect And Copy PHI
You have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as
the Plan maintains the PHI, including your PHI maintained in an electronic format. If your PHI is available in an
electronic format, you may request access electronically and that this be transmitted directly to someone you
designate.
“Protected Health Information” (PHI) includes all individually identifiable health information transmitted or
maintained by the Plan, regardless of form.
“Designated Record Set” includes the medical records and billing records about individuals that are maintained
by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical
management record systems maintained by or for a health plan; or other information used in whole or in part by
or for the covered entity to make decisions about individuals. Information used for quality control or peer review
analyses and not used to make decisions about individuals is not in the designated record set.
The requested information will be provided within 30 days if the information is maintained on site or within 60
days if the information is maintained offsite. A single 30-day extension is allowed if the Plan is unable to comply
with the deadline.
You or your personal representative will be required to complete a form to request access to the PHI in your
designated record set. Requests for access to PHI should be made to the Benefits Director.
If access is denied, you or your personal representative will be provided with a written denial setting forth the
basis for the denial, a description of how you may exercise those review rights and a description of how you
may file a complaint to the Secretary of the U.S. Department of Health and Human Services. Please note that
the Plan Sponsor is only responsible for supplying data that it keeps on file. The Plan Sponsor is not
responsible for supplying data that is kept by the claims payer or by your provider.
Right to Amend PHI
You have the right to request the Plan amend your PHI if you believe there is a mistake in your PHI, or that
important information is missing. Requests for amendment of PHI should be made to the Benefits Director.
Your request for amending a record must be made in writing and must include the reason for making the
amendment.
The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if
the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide
you with a written denial that explains the basis for the denial. You or your personal representative may then
7
submit a written statement disagreeing with the denial and have that statement included with any future
disclosures of your PHI.
Right to Receive an Accounting of PHI Disclosures
At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your PHI,
including a disclosure involving an electronic health record, during the six years (three years in the case of a
disclosure involving an electronic health record) prior to the date of your request. However, such accounting
need not include PHI disclosures made:



to carry out treatment, payment, or health care operations (Note: does not apply to electronic health
records);
to individuals about their own PHI; or
prior to either the compliance date (April 14, 2004) or the date you became a participant in the Plan.
In addition, you have the right to receive reports of any security incidents that the Employer becomes aware of
that is required under the Security Rules.
If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a
written statement of the reasons for the delay and the date by which the accounting will be provided.
If you request more than one accounting within a 12-month period, the Plan may charge a reasonable, costbased fee for each subsequent accounting.
Right To Receive A Paper Copy Of This Notice Upon Request
To obtain a paper copy of this Notice contact your Human Resources representative.
A Note about Personal Representatives
At your request, the Plan will disclose your PHI to someone who is qualified to act as your personal
representative. Your personal representative will be required to produce evidence of his/her authority to act on
your behalf before that person will be given access to your PHI. Proof of such authority may take one of the
following forms:



a power of attorney for health care purposes, notarized by a notary public; or
a court order of appointment of the person as the conservator or guardian of the individual; or
an individual who is the parent of a minor child.
The Plan retains discretion to deny access of your PHI to a personal representative when the plan has a
reasonable belief that you may be subject to abuse or neglect by the person, treating the person as your
personal representative could endanger you or, in the Plans professional judgment, it is not in your best interest
to treat the person as your personal representative. This also applies to personal representatives of minors.
Section 3 – The Plan’s Duties
The Plan is required by law to maintain the privacy of PHI and to provide plan participants with notice of its legal
duties and privacy practices.
The Plan is required to comply with the terms of this notice. However, the Plan reserves the right to change its
privacy and security practices and to apply the changes to any PHI received or maintained by the Plan prior to
that date. If a privacy practice is changed, a revised version of this notice will be provided to plan participants.
Any revised version of this notice will be distributed within 60 days of the effective date of any material change
to the uses or disclosures, the individual’s rights, the duties of the Plan or other privacy practices stated in this
notice.
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Minimum Necessary Standard
When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make
reasonable efforts not to use, disclose, or request more than the minimum amount of PHI necessary to
accomplish the intended purpose, taking into consideration practical and technological limitations.
However, the minimum necessary standard will not apply in the following situations:




uses or disclosures made to the individual;
uses or disclosures made to the Secretary of the U.S. Department of Health and Human Services;
uses or disclosures that are required by law; and
uses or disclosures that are required for the Plan’s compliance with legal regulations.
This notice does not apply to information that has been de-identified. De-identified information is information
that does not identify an individual and with respect to which there is no reasonable basis to believe that the
information can be used to identify an individual is not individually identifiable health information.
In addition, the Plan may use or disclose “summary health information” to the plan sponsor for obtaining
premium bids or modifying, amending or terminating the group health plan. Summary Health Information may
include claims history, claims expenses or type of claims experienced by individuals for whom a plan sponsor
has provided health benefits under a group health plan, and from which identifying information has been deleted
in accordance with HIPAA.
BREACH OF UNSECURED PHI
You must be notified in the event of a breach of unsecured PHI. A “breach” is the acquisition, access, use, or
disclosure of PHI in a manner that compromises the security or privacy of the PHI. PHI is considered
compromised when the breach poses a significant risk of financial harm, damage to your reputation, or other
harm to you. This does not include good faith or inadvertent disclosures or when there is no reasonable way to
retain the information. You must receive a notice of the breach as soon as possible and no later than 60 days
after the discovery of the breach.
Section 4 – Your Right to file a Complaint with the Plan or the HHS Secretary
If you believe that your privacy rights have been violated, you may complain to the Plan Sponsor in care of the
Day & Zimmermann Benefits Director, 1500 Spring Garden Street, Philadelphia, PA 19130.
You may file a complaint with the Office for Civil Rights of the U.S. Department of Health and Human Services,
150 S. Independence Mall West, Suite 372, Public Ledger Building, Philadelphia, PA 19106.
The Plan will not retaliate against you for filing a complaint.
Section 5 – Whom to Contact at the Plan for More Information
If you have any question regarding this notice or the subjects addressed within it, you may contact Day &
Zimmermann, Plan Administrator Benefits Department, 1500 Spring Garden Street, Philadelphia, PA 19130.
Conclusion
PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance
Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and
164. This notice attempts to summarize the regulations. The regulations will supersede any discrepancy
between the information in this notice and the regulations.
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