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 issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

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 mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

   1. All stages of reconstruction of the breast on which the mastectomy was performed;
   2. Surgery and reconstruction of the other breast to produce a symmetrical appearance;
  3. Prostheses and
  4. Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under the plan.

PRESCRIPTION DRUG COVERAGE AND MEDICARE

Information about your current prescription drug coverage thru a group health plan and prescription drug coverage available for those with Medicare.  It also tells you where to find more information to help you make decisions about your prescription drug coverage.

All group health plans thru Complete Benefit Solutions, Inc. is expected, on average, for all plan participants to pay out as much as the standard Medicare prescription drug coverage will pay, and is considered creditable coverage.

Because your existing coverage, is on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and you will not pay extra if you decide to enroll in Medicare prescription coverage at a later date.

If you do decide to enroll in a Medicare prescription drug plan and drop your prescription drug coverage through your group health plan, beware that you and your dependents may not be able to get this coverage back.  You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area.

Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from Nov. 15 thru Dec. 31.  Beneficiaries leaving employer/union coverage may be eligible for a special enrollment period to sign up for a Medicare prescription drug plan.  You also should know that if you drop or lose your coverage thru your group health plan and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later.

If you go 63 days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly premium will go up at least 1 percent per month for every month that you did not have that coverage.  For example, if you go 19 months without coverage, your premium will always be at least 19 percent higher than what many other people pay.  You’ll have to pay this higher premium as long as you have Medicare coverage.  In addition, you may have to wait until the next November to enroll.

For more information about your current prescription drug coverage, contact Complete Benefits Solutions, Inc. at 866-887-2274  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 also may be contacted directly by Medicare prescription drug plans.  For more information about Medicare prescription drug plans:

    
    Visit www.medicare.gov for personalized help.

    Call your State Health Insurance Assistance Program (see your copy of the
    “Medicare & You” handbook for telephone numbers).

    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 1-800-772-1213
(TTY 1-800-325-0778).

The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that we notify you of two very important provision in the plan. The first is your right to enroll in the plan under its “special enrollment provision” if you acquire a new dependent, or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. Second, this notice advises you of the plan’s pre-existing exclusion rules, who it applies to & who it doesn’t apply to.

Special Enrollment Provision for Loss of Other Coverage (Excluding Medicaid or a State Children’s Health Insurance Program). If you decline enrollment for yourself or your eligible dependents (including your spouse) in this plan while other health insurance coverage is in effect, you may in the future 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), provided you request enrollment within 30 days after your other coverage ends (or after the employer stops contributing toward the other coverage).

Loss of Coverage for Medicaid or a State Children’s Health Insurance Program. 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 you or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.

New Dependent by Marriage, Birth, Adoption or Placement for Adoption. 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 a State Children’s Health Insurance Program. 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 you or your dependents’ determination of eligibility for such assistance.

Applies to adults & dependent children 19 years old & over 19:
Federal law may affect your group health coverage if you are enrolled or become eligible to enroll in group health plan or health insurance coverage that limits or excludes coverage for pre-existing medical conditions. HIPAA limits the circumstances that coverage may be limited or excluded for medical conditions present before you enroll.

This plan imposes a pre-existing condition exclusion. 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 the six-month period prior to hire date. Generally, this six-month 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 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.

Under the law, a pre-existing condition exclusion generally may not be imposed for more than 12 months (18 months for 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, the 12-month (or 18-month) exclusion period is reduced 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, assuming there were no breaks in coverage of 63 or more days.

To reduce the 12-month (or18-month) exclusion period by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate of creditable coverage, but you do have prior health insurance coverage, please contact your prior plan & request one.

No Pre-Existing Condition Exclusions for Children Under Age 19.
The Affordable Care Act’s New Patient’s Bill of Rights states that for plans effective on or after September 23, 2010 there will be no pre-existing condition limitations or exclusions for children under the age of 19.

The Mental Health Parity Act provides for parity in the application of annual and lifetime dollar limits on mental benefits with annual & lifetime dollar limits on medical/surgical benefits. For new plans or plans that renew on September 23, 2010 and after, according to the Affordable Care Act, plans can no longer have lifetime limits on coverage.

The Mental Health Parity and Addiction Equity Act provides for parity in the application of annual and lifetime dollar limits on mental and substance abuse benefits with annual and lifetime dollar limits on medical/surgical benefits. For new plans or plans that renew on September 23, 2010 and after, according to the Affordable Care Act, plans can no longer have lifetime limits on coverage.

USERRA gives employees serving in the military (either reserves or on full-time duty) the right to continue health coverage, similar to rights under COBRA, but for 24 months.

The Patient Protection and Affordable Care Act (PPACA) bans the use of lifetime limits and will allow restricted annual limits until 2014 when any annual limits are prohibited.

According to The Affordable Care Act’s New Patient’s Bill of Rights starting September 23, 2010, children under the age of 26 will be allowed to stay on their parent’s family policy, or be added to it, only if the adult child is not eligible OR doesn’t have another offer of employment-based coverage.

Individuals whose coverage ended, or who were denied coverage, because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in a group health plan, provided they are not eligible or doesn’t have another offer of employment-based coverage. Individuals may request enrollment for such children for 30 days from the first day of the first plan or policy year beginning on or after September 23, 2010. For more information contact Complete Benefit Solutions, Inc. at 1-866-887-2274.

According to The Affordable Care Act’s New Patient’s Bill of Rights starting September 23, 2010, children under the age of 26 will be allowed to stay on their parent’s family policy, or be added to it, even if the young adult no longer lives with his or her parents, is not a dependent on a parent’s tax return, or is no longer a student. This applies to both married and unmarried children, although their own spouses and children do not qualify.

Individuals whose coverage ended, or who were denied coverage, because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in a group health plan. Individuals may request enrollment for such children for 30 days from the first day of the first plan or policy year beginning on or after September 23, 2010. For more information contact Complete Benefit Solutions, Inc. at 1-866-887-2274.

According to the Public Health Service Act (PHS Act) section 2719A, if a group health plan provides any benefits for emergency services in an emergency department of a hospital, the plan must pay the in-network level of benefits to out-of-network emergency room treatment of emergency medical conditions. This includes radiology, lab services, and any related services pertaining to that emergency room visit. The out-of-network provider may “balance bill” the patient

PREVENTIVE CARE COVERAGE

 

PREVENTIVE CARE SERVICES

The Patient Protection and Affordable Care Act (PPACA) provides for specific preventive services when provided by participating providers to be covered at 100 percent starting October 1, 2010 for all new plans and for renewing plans that are not grandfathered plans.

 

COVERAGE FOR PREVENTIVE SERVICES

Here are some examples of the preventive services that will be covered with no co-pay, coinsurance or deductible.

 

Child Preventive	Adult Preventive
Exams:  Preventive office visits including                well child care	Exams:  Preventive office visits including well woman exam
Immunizations: Influenza (flu) Pneumonia Hepatitis A Hepatitis B Diptheria, Tetanus, Pertussis Varicella (chicken pox) Polio Rotavirus Meningococcal Human Papillomavirus (HPV)	Immunizations: Influenza (flu) Pneumonia Hepatitis A Hepatitis B         Diptheria, Tetanus, Pertussis Varicella (chicken pox) Polio         Rotavirus Meningococcal
Screening Tests:  Hearing screening, Eye chart screening PKU screening (newborns), Sickle cell screening (newborns)     Newborn Preventive Treatment:  Gonorrhea treatment	Screening Tests:  Breast cancer screening, Cervical cancer screening, Colorectal cancer Screening, Prostate cancer screening, Bone density, Lipid panels, Abdominal aneurysm aortic screening, Screening for sexually transmitted diseases, HIV test, General and immunological labs, Routine blood and urine screenings

 

 

The list is subject to change as federal guidance is issued.  The full list of covered preventive services

 issued with the Interim Final Rules can be found at:

 http://www.healthcare.gov/center/regulations/prevention/taskforce.html

______________________________________________________________________________________

Talking with Your Provider about Preventive Care

We process claims based on your provider’s clinical assessment of the office visit.  If a preventive item or

service is billed separately, cost-sharing may apply to the office visit.  If the primary reason for your visit

is seeking treatment for an illness or condition, and preventive care is administered during the same visit,

cost-sharing may apply.  This means your provider may ask you to pay your appropriate health plan co-pay,

deductible or coinsurance.

 

Certain screening services, such as a colonoscopy or mammogram, may identify health conditions that require

further testing or treatment.  If a condition is identified through a preventive screening, any subsequent testing.

diagnosis, analysis or treatment are not considered preventive services and are subject to the appropriate

cost-sharing.

A “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act).  As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.  Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that  apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at  1-866-887-2274.  You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform.

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 November 3, 2010.  You should contact your State for further information on eligibility –

 

 

ALABAMA – Medicaid	CALIFORNIA – Medicaid
Website: http://www.medicaid.alabama.gov   Phone: 1-800-362-1504	Website: http://www.dhcs.ca.gov/services/Pages/ TPLRD_CAU_cont.aspx   Phone: 1-866-298-8443
ALASKA – Medicaid	COLORADO – Medicaid and CHIP
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/   Phone (Outside of Anchorage): 1-888-318-8890   Phone (Anchorage): 907-269-6529	Medicaid Website: http://www.colorado.gov/   Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943   CHIP Website: http:// www.CHPplus.org   CHIP Phone: 303-866-3243
ARIZONA – CHIP
Website: http://www.azahcccs.gov/applicants/default.aspx   Phone (In state): 1-877-764-5437
ARKANSAS – CHIP	FLORIDA – Medicaid
Website: http://www.arkidsfirst.com/   Phone: 1-888-474-8275	Website: http://www.fdhc.state.fl.us/Medicaid/index.shtml   Phone: 1-866-762-2237
GEORGIA – Medicaid	MONTANA – Medicaid
Website: http://dch.georgia.gov/       Click on Programs, then Medicaid   Phone: 1-800-869-1150	Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml   Telephone: 1-800-694-3084
IDAHO – Medicaid and CHIP	NEBRASKA – Medicaid
Medicaid Website: www.accesstohealthinsurance.idaho.gov   Medicaid Phone: 1-800-926-2588   CHIP Website: www.medicaid.idaho.gov   CHIP Phone: 1-800-926-2588	Website: http://www.dhhs.ne.gov/med/medindex.htm   Phone: 1-877-255-3092
INDIANA – Medicaid	NEVADA – Medicaid and CHIP
Website: http://www.in.gov/fssa/2408.htm   Phone: 1-877-438-4479	Medicaid Website:  http://dwss.nv.gov/   Medicaid Phone:  1-800-992-0900   CHIP Website: http://www.nevadacheckup.nv.org/   CHIP Phone: 1-877-543-7669
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/   Phone: 1-888-346-9562
KANSAS – Medicaid	NEW HAMPSHIRE – Medicaid
Website: https://www.khpa.ks.gov   Phone: 800-766-9012	Website: www.dhhs.nh.gov/ombp/index.htm   Phone: 603-271-4238
KENTUCKY – Medicaid	NEW JERSEY – Medicaid and CHIP
Website: http://chfs.ky.gov/dms/default.htm   Phone: 1-800-635-2570	Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/   Medicaid Phone: 1-800-356-1561   CHIP Website: http://www.njfamilycare.org/index.html   CHIP Phone: 1-800-701-0710
LOUISIANA – Medicaid
Website: http://www.lahipp.dhh.louisiana.gov   Phone: 1-888-342-6207
MAINE – Medicaid	NEW MEXICO – Medicaid and CHIP
Website: http://www.maine.gov/dhhs/oms/   Phone: 1-800-321-5557	Medicaid Website: http://www.hsd.state.nm.us/mad/index.html   Medicaid Phone: 1-888-997-2583   CHIP Website: http://www.hsd.state.nm.us/mad/index.html       Click on Insure New Mexico   CHIP Phone: 1-888-997-2583
MASSACHUSETTS – Medicaid and CHIP
Medicaid & CHIP Website: http://www.mass.gov/MassHealth   Medicaid & CHIP Phone: 1-800-462-1120
MINNESOTA – Medicaid	NEW YORK – Medicaid
Website: http://www.dhs.state.mn.us/       Click on Health Care, then Medical Assistance   Phone (Outside of Twin City area): 800-657-3739   Phone (Twin City area): 651-431-2670	Website: http://www.nyhealth.gov/health_care/ medicaid/   Phone: 1-800-541-2831
MISSOURI – Medicaid	NORTH CAROLINA – Medicaid
Website: http://www.dss.mo.gov/mhd/index.htm   Phone: 573-751-6944	Website:  http://www.nc.gov   Phone:  919-855-4100
NORTH DAKOTA – Medicaid	UTAH – Medicaid
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/   Phone: 1-800-755-2604	Website: http://health.utah.gov/medicaid/   Phone: 1-866-435-7414
OKLAHOMA – Medicaid	VERMONT– Medicaid
Website: http://www.insureoklahoma.org   Phone: 1-888-365-3742	Website: http://ovha.vermont.gov/   Telephone: 1-800-250-8427
OREGON – Medicaid and CHIP	VIRGINIA – Medicaid and CHIP
Medicaid & CHIP Website: http://www.oregonhealthykids.gov   Medicaid & CHIP Phone: 1-877-314-5678	Medicaid Website:  http://www.dmas.virginia.gov/rcp-HIPP.htm   Medicaid Phone:  1-800-432-5924   CHIP Website: http://www.famis.org/   CHIP Phone: 1-866-873-2647
PENNSYLVANIA – Medicaid	WASHINGTON – Medicaid
Website: http://www.dpw.state.pa.us/partnersproviders/medicalassistance/doingbusiness/003670053.htm   Phone: 1-800-644-7730	Website:  http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm   Phone:  1-800-562-3022 ext. 15473
RHODE ISLAND – Medicaid	WEST VIRGINIA – Medicaid
Website: www.dhs.ri.gov   Phone: 401-462-5300	Website:  http://www.wvrecovery.com/hipp.htm   Phone:  304-342-1604
SOUTH CAROLINA – Medicaid	WISCONSIN – Medicaid
Website: http://www.scdhhs.gov   Phone: 1-888-549-0820	Website: http://dhs.wisconsin.gov/medicaid/publications/p-10095.htm   Phone: 1-800-362-3002
TEXAS – Medicaid	WYOMING – Medicaid
Website: https://www.gethipptexas.com/   Phone: 1-800-440-0493	Website: http://www.health.wyo.gov/healthcarefin/index.html   Telephone: 307-777-7531

 

To see if any more States have added a premium assistance program since November 3, 2010, or for more information on special enrollment rights, you can contact either:

 

U.S. Department of Labor		U.S. Department of Health and Human Services
Employee Benefits Security Administration		Centers for Medicare & Medicaid Services
www.dol.gov/ebsa		www.cms.hhs.gov
1-866-444-EBSA (3272)		1-877-267-2323, Ext. 61565

** Continuation Coverage Rights Under COBRA** This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan.  This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it.  

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).  COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage.  It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage.  For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.  

What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.”  Specific qualifying events are listed later in this notice.  After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”  You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.  Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. 
If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:

   Your hours of employment are reduced, or    Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens:

   Your spouse dies;
   Your spouse’s hours of employment are reduced;
   Your spouse’s employment ends for any reason other than his or her gross misconduct;    
   Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens:

   The parent-employee dies;
   The parent-employee’s hours of employment are reduced;
   The parent-employee’s employment ends for any reason other than his or her gross misconduct;
   The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
   The parents become divorced or legally separated; or the child stops being eligible for coverage under the plan as a “dependent child.”

When is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred.  When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.
You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.  You must provide this notice to: Complete Benefit Solutions, Inc.  1113 S. Range Ave., Suite 110-325  Denham Springs, LA  70726
How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries.  Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.  Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.  

COBRA continuation coverage is a temporary continuation of coverage.  When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months.  When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement.  For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months).  Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months.  There are three ways in which this 18-month period of COBRA continuation coverage can be extended.  

Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months.  The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage.  To qualify for disability extension, the qualified beneficiary must also provide the plan administrator with notice of the disability determination on a date that is both within 60 days after the date of the determination and before the end of the original 18-month maximum coverage.  Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies.  If the qualified beneficiary is determined to no longer be disabled under the SSA, you must notify the Plan of that fact within 30 days after that determination.

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan.  This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Military Leave

On Dec. 10, President Bush signed into law language that amends the continuation coverage requirements in the Uniformed Services Employment and Re-employment Act of 1994 (USERRA).  That language is part of the Veterans’ Benefits Improvements Act of 2004
 (Pub.L 108-454).

USERRA’s continuation coverage requirements require that eligible employees who are called to military active duty must be given an opportunity to continue group health coverage for themselves (and their spouse and dependents) for up to 24 months.  This extension will be provided for individuals electing coverage beginning on and after the December 10 enactment date.  Therefore, the extension does not extend a continuation coverage period that had already begun before enactment.
If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below.  For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa.  (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members.  You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Plan Contact Information Complete Benefit Solutions, Inc.
1113 South Range Avenue
Suite 110-325
Denham Springs, LA  70726
866-887-2274

NOTICE OF PRIVACY PRACTICES

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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.  THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

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Summary of Privacy Practices
    “We,” as a Group Health Plan, may use and disclose your medical information, without your permission, for treatment, payment, and health care operations activities and when required or authorized by law enforcement, judicial and administrative proceedings, research, and certain other public benefit functions.

    We may disclose your medical information to your spouse and others you involve in your health care or payment for health care and to appropriate public and private agencies in disaster relief situations.

    We may disclose to your Plan Sponsor/Employer whether you are enrolled or disenrolled in the health plan it sponsors, summary health information for certain limited purposes, and your medical information for your Plan Sponsor/Employer to administer your group health plan if your plan Sponsor/Employer explains the limitations on its use and disclosure of your medical information in the plan document for your group health plan.

    We will not otherwise use or disclose your medical information without your written authorization.

    You have the right to examine and receive a copy of your medical information, to receive an accounting of certain disclosures we may make of your medical information, and to request that we amend, further restrict use and disclosure of, or communicate in confidence with you about your medical information.

    Please review this entire notice for details about the uses and disclosures we may make of your medical information, about your rights and how to exercise them, and about complaints, regarding or additional information about our privacy practices.

Our Legal Duty     We are required by applicable federal and state law to maintain the privacy of your medical information.  We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information.  We must follow the privacy practices that are described in this notice while it is in effect.  This notice takes effect September 16, 2010, and will remain in effect unless we replace it.

    We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law.  We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes.  Before we make a significant change in our privacy practices, we will change this notice and send the new notice to our health plan subscribers at the time of the change.

    You may request a copy of our notice at any time.  For more information about our privacy practices, or for additional copies of this notice, please use the contact information at the end of this notice.


Uses and Disclosures of Medical Information
    Treatment:  We may disclose your medical information, without your permission, to a physician or other health care provider to treat you.

    Payment:  We may use and disclose your medical information, without your permission, to pay claims from physicians, hospitals and other health care providers for services delivered to you that are covered by your health plan, to determine your eligibility for benefits, to coordinate your benefits with other payers, to determine the medical necessity of care delivered to you, to obtain reinsurance premiums for your health coverage, to issue explanations of benefits to the subscriber of the health plan in which you participate, and the like.  We may disclose your medical information to a health care provider or another health plan for that provider or plan to obtain payment or engage in other payment activities.

    Health Care Operations:  We may use and disclose your medical information, without your permission, for health care operations.  Health care operations include:

  Health care quality assessment and improvement activities;
  Reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing and credentialing activities;
  Conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention;
  Underwriting and premium rating our risk for health coverage, and obtaining stop-loss and similar reinsurance for our health coverage obligations;
  Business planning, development, management, and general business administration, including customer service, grievance resolution, claims payment and health coverage improvement activities, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.

    We may disclose your medical information to another health plan or to a health care provider subject to federal privacy protection laws, as long as the plan or provider has or had a relationship with you and the medical information is for that plan’s or provider’s health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

    Your Authorization:  You may give us written authorization to use your medical information or to disclose it to anyone for any purpose.  If you give us an authorization, you may revoke it in writing at any time.  Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect.  Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than described in this notice.

    Spouses and Others Involved in Your Care or Payment for Care:  We may disclose your medical information to a spouse covered under your benefit plan.  We will disclose only the medical information that is relevant to your spouse’s involvement.  We may also use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your health care in appropriate situations, such as a medical emergency or during disaster relief efforts.

    If you are present at the time of the disclosure, we will provide you with an opportunity to object.  If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing your medical information is in your best interest under the circumstances.

    Your Plan Sponsor/Employer:  We may disclose to your plan Sponsor/Employer whether you are enrolled or disenrolled in a health plan.  We may disclose summary health information to your Plan Sponsor/Employer to use to obtain reinsurance bids for the health insurance coverage offered under the group health plan in which you participate or to decide whether to modify, amend or terminate that group health plan.  Summary health information is aggregated claims history, claims expenses or types of claims experienced by the enrollees in your group health plan.  Although summary health information will be stripped of all direct identifiers of these enrollees, it still may be possible to identify medical information contained in the summary health information as yours.

    We may disclose your medical information and the medical information of others enrolled in your group health plan to your Plan Sponsor/Employer to administer your group health plan.  Before we may do that, your Plan Sponsor/Employer must amend the plan document for your group health plan to establish the limited uses and disclosures it may make of your medical information.

    Health-Related Products and Services:  We may use your medical information to communicate with you about health-related products, benefits and services, and payment for those products, benefits and services, that we provide or include in our benefits plan, and about treatment alternatives that may be of interest to you.  These communications may include information about the health care providers in our network, about replacement of or enhancements to your health plan, and about health-related products or services that are available only to our enrollees that add value to, although they are not part of, our benefits plan.

    Public Health and Benefit Activities:  We may use and disclose your medical information, without your permission, when required by law, and when authorized by law for the following kinds of public health and interest activities, judicial and administrative proceedings, law enforcement, research, and other public benefit functions:

  For public health, including to report disease and vital statistics, child abuse, and adult abuse, neglect or domestic violence;
  To avert a serious and imminent threat to health or safety;
  For health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities, and fraud enforcement agencies;   For research;
  In response to court and administrative orders and other lawful process;
  To law enforcement officials, with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying or locating suspects or other persons;
  To coroners, medical examiners, funeral directors, and organ procurement organizations;
  To the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
  As authorized by state worker’s compensation laws.

Individual Rights

    Access:  You have the right to examine and to receive a copy of your medical information, with limited exceptions.  You must make a written request to obtain access to your medical information.  You should submit your request to the contact at the end of this notice.  You may obtain a form from that contract to make your request.

    We may charge you reasonable, cost-based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request.

    Disclosure Accounting:  You have the right to a list of instances after April 14, 2003, in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities.

    You should submit your request to the contact at the end of this notice.  You may obtain a form from that contact to make your request.  We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request and never for a disclosure that occurred before April 14, 2003.  If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to your additional requests.

    Amendment:  You have the right to request that we amend your medical information.  Your request must be in writing, and it must explain why the information should be amended.  You should submit your request to the contact at the end of this notice.  You may obtain a form from that contact to make your request.

    We may deny your request only for certain reasons.  If we deny your request, we will provide you a written explanation.  If we accept your request, we will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who we know may have and rely on the unamended information to your detriment, as well as persons who want to receive the amendment.

    Restriction:  You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify.

We are not required to agree to your request.  If we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law.  You should submit your request to the contact at the end of this notice.  You may obtain a form from that contact to make your request.  Any agreement we may make to a request for restriction must be in writing signed by a person authorized to bind us to such an agreement.

    Confidential Communications:  You have the right to request that we communicate with you about your medical information in confidence by alternative means or to alternative locations that you specify.  You must make your request in writing, and your request must represent that the information could endanger you if it is not communicated in confidence as you request.  You should submit your request to the contact at the end of this notice.  You may obtain a form from that contact to make your request.

    We will accommodate your request if it is reasonable, specifies the alternative means or location for confidential communications, and continues to permit us to collect premiums and pay claims under your health plan, including issuance of explanations of benefits to the participant of that health plan.  Please note that an explanation of benefits and other information that we issue to the participant about health care that you received for which you did not request confidential communications, or about health care received by
The participant or by others by the health plan in which you participate, may contain sufficient information to reveal that you obtained health care for which we paid, even though you requested that we communicate with you about that health care in confidence.

    Electronic Notice:  If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form.  Please contact us using the information at the end of this notice to obtain this notice in written form.

    

Who do I contact?

Questions and Complaints

If you disagree with a decision we made about access to your medical information, in a response to a request you made to amend, restrict the use or disclosure of, or communicate in confidence about your medical information, you may complain using the contact information at the end of this notice.  You also may submit a written complaint to the Office of Civil Rights of the United States Department of Health and Human Services, 2200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201.  You may contact the Office of Civil Rights’ Hotline at 1-800-368-1019.

We support your right to the privacy of your medical information.  We will not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health and Human Services.

** Continuation Coverage Rights Under COBRA** This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan.  This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it.  

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).  COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage.  It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage.  For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.  

What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.”  Specific qualifying events are listed later in this notice.  After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”  You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.  Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. 
If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:

   Your hours of employment are reduced, or    Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens:

   Your spouse dies;
   Your spouse’s hours of employment are reduced;
   Your spouse’s employment ends for any reason other than his or her gross misconduct;    
   Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens:

   The parent-employee dies;
   The parent-employee’s hours of employment are reduced;
   The parent-employee’s employment ends for any reason other than his or her gross misconduct;
   The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
   The parents become divorced or legally separated; or the child stops being eligible for coverage under the plan as a “dependent child.”

When is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred.  When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.
You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.  You must provide this notice to: Complete Benefit Solutions, Inc.  1113 S. Range Ave., Suite 110-325  Denham Springs, LA  70726
How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries.  Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.  Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.  

COBRA continuation coverage is a temporary continuation of coverage.  When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months.  When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement.  For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months).  Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months.  There are three ways in which this 18-month period of COBRA continuation coverage can be extended.  

Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months.  The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage.  To qualify for disability extension, the qualified beneficiary must also provide the plan administrator with notice of the disability determination on a date that is both within 60 days after the date of the determination and before the end of the original 18-month maximum coverage.  Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies.  If the qualified beneficiary is determined to no longer be disabled under the SSA, you must notify the Plan of that fact within 30 days after that determination.

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan.  This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Military Leave

On Dec. 10, President Bush signed into law language that amends the continuation coverage requirements in the Uniformed Services Employment and Re-employment Act of 1994 (USERRA).  That language is part of the Veterans’ Benefits Improvements Act of 2004
 (Pub.L 108-454).

USERRA’s continuation coverage requirements require that eligible employees who are called to military active duty must be given an opportunity to continue group health coverage for themselves (and their spouse and dependents) for up to 24 months.  This extension will be provided for individuals electing coverage beginning on and after the December 10 enactment date.  Therefore, the extension does not extend a continuation coverage period that had already begun before enactment.
If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below.  For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa.  (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members.  You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Plan Contact Information Complete Benefit Solutions, Inc.
1113 South Range Avenue
Suite 110-325
Denham Springs, LA  70726
866-887-2274

NOTICE OF PRIVACY PRACTICES

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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.  THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

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Summary of Privacy Practices
    “We,” as a Group Health Plan, may use and disclose your medical information, without your permission, for treatment, payment, and health care operations activities and when required or authorized by law enforcement, judicial and administrative proceedings, research, and certain other public benefit functions.

    We may disclose your medical information to your spouse and others you involve in your health care or payment for health care and to appropriate public and private agencies in disaster relief situations.

    We may disclose to your Plan Sponsor/Employer whether you are enrolled or disenrolled in the health plan it sponsors, summary health information for certain limited purposes, and your medical information for your Plan Sponsor/Employer to administer your group health plan if your plan Sponsor/Employer explains the limitations on its use and disclosure of your medical information in the plan document for your group health plan.

    We will not otherwise use or disclose your medical information without your written authorization.

    You have the right to examine and receive a copy of your medical information, to receive an accounting of certain disclosures we may make of your medical information, and to request that we amend, further restrict use and disclosure of, or communicate in confidence with you about your medical information.

    Please review this entire notice for details about the uses and disclosures we may make of your medical information, about your rights and how to exercise them, and about complaints, regarding or additional information about our privacy practices.

Our Legal Duty     We are required by applicable federal and state law to maintain the privacy of your medical information.  We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your medical information.  We must follow the privacy practices that are described in this notice while it is in effect.  This notice takes effect September 16, 2010, and will remain in effect unless we replace it.

    We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law.  We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes.  Before we make a significant change in our privacy practices, we will change this notice and send the new notice to our health plan subscribers at the time of the change.

    You may request a copy of our notice at any time.  For more information about our privacy practices, or for additional copies of this notice, please use the contact information at the end of this notice.


Uses and Disclosures of Medical Information
    Treatment:  We may disclose your medical information, without your permission, to a physician or other health care provider to treat you.

    Payment:  We may use and disclose your medical information, without your permission, to pay claims from physicians, hospitals and other health care providers for services delivered to you that are covered by your health plan, to determine your eligibility for benefits, to coordinate your benefits with other payers, to determine the medical necessity of care delivered to you, to obtain reinsurance premiums for your health coverage, to issue explanations of benefits to the subscriber of the health plan in which you participate, and the like.  We may disclose your medical information to a health care provider or another health plan for that provider or plan to obtain payment or engage in other payment activities.

    Health Care Operations:  We may use and disclose your medical information, without your permission, for health care operations.  Health care operations include:

  Health care quality assessment and improvement activities;
  Reviewing and evaluating health care provider and health plan performance, qualifications and competence, health care training programs, health care provider and health plan accreditation, certification, licensing and credentialing activities;
  Conducting or arranging for medical reviews, audits, and legal services, including fraud and abuse detection and prevention;
  Underwriting and premium rating our risk for health coverage, and obtaining stop-loss and similar reinsurance for our health coverage obligations;
  Business planning, development, management, and general business administration, including customer service, grievance resolution, claims payment and health coverage improvement activities, de-identifying medical information, and creating limited data sets for health care operations, public health activities, and research.

    We may disclose your medical information to another health plan or to a health care provider subject to federal privacy protection laws, as long as the plan or provider has or had a relationship with you and the medical information is for that plan’s or provider’s health care quality assessment and improvement activities, competence and qualification evaluation and review activities, or fraud and abuse detection and prevention.

    Your Authorization:  You may give us written authorization to use your medical information or to disclose it to anyone for any purpose.  If you give us an authorization, you may revoke it in writing at any time.  Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect.  Unless you give us a written authorization, we will not use or disclose your medical information for any purpose other than described in this notice.

    Spouses and Others Involved in Your Care or Payment for Care:  We may disclose your medical information to a spouse covered under your benefit plan.  We will disclose only the medical information that is relevant to your spouse’s involvement.  We may also use or disclose your name, location, and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your health care in appropriate situations, such as a medical emergency or during disaster relief efforts.

    If you are present at the time of the disclosure, we will provide you with an opportunity to object.  If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing your medical information is in your best interest under the circumstances.

    Your Plan Sponsor/Employer:  We may disclose to your plan Sponsor/Employer whether you are enrolled or disenrolled in a health plan.  We may disclose summary health information to your Plan Sponsor/Employer to use to obtain reinsurance bids for the health insurance coverage offered under the group health plan in which you participate or to decide whether to modify, amend or terminate that group health plan.  Summary health information is aggregated claims history, claims expenses or types of claims experienced by the enrollees in your group health plan.  Although summary health information will be stripped of all direct identifiers of these enrollees, it still may be possible to identify medical information contained in the summary health information as yours.

    We may disclose your medical information and the medical information of others enrolled in your group health plan to your Plan Sponsor/Employer to administer your group health plan.  Before we may do that, your Plan Sponsor/Employer must amend the plan document for your group health plan to establish the limited uses and disclosures it may make of your medical information.

    Health-Related Products and Services:  We may use your medical information to communicate with you about health-related products, benefits and services, and payment for those products, benefits and services, that we provide or include in our benefits plan, and about treatment alternatives that may be of interest to you.  These communications may include information about the health care providers in our network, about replacement of or enhancements to your health plan, and about health-related products or services that are available only to our enrollees that add value to, although they are not part of, our benefits plan.

    Public Health and Benefit Activities:  We may use and disclose your medical information, without your permission, when required by law, and when authorized by law for the following kinds of public health and interest activities, judicial and administrative proceedings, law enforcement, research, and other public benefit functions:

  For public health, including to report disease and vital statistics, child abuse, and adult abuse, neglect or domestic violence;
  To avert a serious and imminent threat to health or safety;
  For health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities, and fraud enforcement agencies;   For research;
  In response to court and administrative orders and other lawful process;
  To law enforcement officials, with regard to crime victims, crimes on our premises, crime reporting in emergencies, and identifying or locating suspects or other persons;
  To coroners, medical examiners, funeral directors, and organ procurement organizations;
  To the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
  As authorized by state worker’s compensation laws.

Individual Rights

    Access:  You have the right to examine and to receive a copy of your medical information, with limited exceptions.  You must make a written request to obtain access to your medical information.  You should submit your request to the contact at the end of this notice.  You may obtain a form from that contract to make your request.

    We may charge you reasonable, cost-based fees for a copy of your medical information, for mailing the copy to you, and for preparing any summary or explanation of your medical information you request.

    Disclosure Accounting:  You have the right to a list of instances after April 14, 2003, in which we disclose your medical information for purposes other than treatment, payment, health care operations, as authorized by you, and for certain other activities.

    You should submit your request to the contact at the end of this notice.  You may obtain a form from that contact to make your request.  We will provide you with information about each accountable disclosure that we made during the period for which you request the accounting, except we are not obligated to account for a disclosure that occurred more than 6 years before the date of your request and never for a disclosure that occurred before April 14, 2003.  If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to your additional requests.

    Amendment:  You have the right to request that we amend your medical information.  Your request must be in writing, and it must explain why the information should be amended.  You should submit your request to the contact at the end of this notice.  You may obtain a form from that contact to make your request.

    We may deny your request only for certain reasons.  If we deny your request, we will provide you a written explanation.  If we accept your request, we will make your amendment part of your medical information and use reasonable efforts to inform others of the amendment who we know may have and rely on the unamended information to your detriment, as well as persons who want to receive the amendment.

    Restriction:  You have the right to request that we restrict our use or disclosure of your medical information for treatment, payment or health care operations, or with family, friends or others you identify.

We are not required to agree to your request.  If we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law.  You should submit your request to the contact at the end of this notice.  You may obtain a form from that contact to make your request.  Any agreement we may make to a request for restriction must be in writing signed by a person authorized to bind us to such an agreement.

    Confidential Communications:  You have the right to request that we communicate with you about your medical information in confidence by alternative means or to alternative locations that you specify.  You must make your request in writing, and your request must represent that the information could endanger you if it is not communicated in confidence as you request.  You should submit your request to the contact at the end of this notice.  You may obtain a form from that contact to make your request.

    We will accommodate your request if it is reasonable, specifies the alternative means or location for confidential communications, and continues to permit us to collect premiums and pay claims under your health plan, including issuance of explanations of benefits to the participant of that health plan.  Please note that an explanation of benefits and other information that we issue to the participant about health care that you received for which you did not request confidential communications, or about health care received by
The participant or by others by the health plan in which you participate, may contain sufficient information to reveal that you obtained health care for which we paid, even though you requested that we communicate with you about that health care in confidence.

    Electronic Notice:  If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form.  Please contact us using the information at the end of this notice to obtain this notice in written form.

    

Who do I contact?

Questions and Complaints

If you disagree with a decision we made about access to your medical information, in a response to a request you made to amend, restrict the use or disclosure of, or communicate in confidence about your medical information, you may complain using the contact information at the end of this notice.  You also may submit a written complaint to the Office of Civil Rights of the United States Department of Health and Human Services, 2200 Independence Avenue, SW, Room 509F, Washington, D.C. 20201.  You may contact the Office of Civil Rights’ Hotline at 1-800-368-1019.

We support your right to the privacy of your medical information.  We will not retaliate in any way if you choose to file a complaint with us or the U.S. Department of Health and Human Services.