North East Independent School District

Transcription

1 8961 TESORO DRIVE, SUITE 209 SAN ANTONIO, TEXAS Phone , Fax Risk Management and Employee Benefits Department MEMO TO: SUBJECT: All Employees and Eligible Dependents CONTINUATION OF HEALTH COVERAGE UPON GROUP INELIGIBILITY (NEISD) will offer continued health coverage to employees and their eligible dependents who no longer meet the District eligibility requirements. This coverage is offered under the conditions set forth by the Consolidated Omnibus Budget Reconciliation Act of 1985, more commonly called COBRA, and as amended by the Omnibus Budget Reconciliation Act of The qualifying events under which an employee and/or dependent will be eligible to continue coverage are: A reduction in hours; An employee s death; Voluntary or involuntary termination of employment (other than for gross misconduct); Retirement; Divorce or legal separation; The employee s or eligible dependent s entitlement to Medicare benefits; A dependent child who is no longer eligible for coverage under the applicable plan provisions; or Leaves other than FMLA, e.g., educational, military, workers compensation (except when integrated with FMLA). The coverage would apply to an individual (known as a qualified beneficiary ) who, on the day before the qualifying event, was: The covered spouse of the employee; A covered dependent child of the covered employee; or A covered employee, in the event of termination. AN EQUAL OPPORTUNITY EMPLOYER

2 CONTINUATION OF HEALTH COVERAGE UPON GROUP INELIGIBILITY Continued A qualified beneificiary has at least sixty (60) days from the date of the termination or other qualifying event in which to elect continuing coverage, and no less than sixty (60) days after receiving notice of the right to continue coverage. In the case of a divorce or a dependent child who is no longer eligible, the covered employee or qualified beneficiary has the responsibility of notifying the Employee Benefits Office in writing within thirty-one (31) days of the status change. The continued coverage will be identical to the health coverage provided to the active employee and their dependents. Coverage would begin on the date of ineligibility due to the qualifying event and ends on the earliest of the following: Eighteen (18) months for employee whose employment has terminated or whose hours have been reduced; Thirty-six (36) months for widows, divorced spouses, dependent children, and spouses of covered employees who become entitled to Medicare benefits; The date on which the employer ceases to provide a group health plan to any employee (the replacing carrier must cover the individual on continuation); The date on which coverage ceases under the plan because of failure, on the part of the beneficiary, to make timely payment of premium required; The date (after the date of election) on which the qualified beneficiary becomes entitled to benefits under Medicare; COBRA continuation coverage WILL NOT cease if a qualified beneficiary becomes covered under another group health plan that contains an exclusion with regards to pre-existing conditions (effective 12/31/89); Qualified beneficiaries determined to be disabled under the Social Security Act at the time a qualifying event occurs, can extend COBRA continuation coverage for eleven (11) additional months provided notification requirements are met. The qualified beneficiary has a forty-five (45) day period from the date he or she elects continuation to pay the first premium. The cost will be the full premium, without district contribution, plus a two percent (2%) service charge to be paid directly to NEISD. Coverage cannot be verified until the first premium is received. For more information, please contact the Employee Benefits Office at Rev. 07/10 AN EQUAL OPPORTUNITY EMPLOYER

3 New Health Insurance Marketplace Coverage O ptions and Your Health Coverage Form Approved OMB No (expires ) PART A: General Information When key parts of the health care law take effect in 201 4, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assis t you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employm ent-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace o f fers "one- stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind o f tax c redit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify t o save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn 't meet certain standards. The savings on your premium that you 're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an o ffer of health coverage from your em ployer that meets certain standards, you w ill not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible f o r a tax c redit that lowers your monthly premium, or a reduction in certain cost- sharing if your employer does not offer coverage to you at all or does not offer cove rage that meets certain standard s. If the cost of a plan from your employer that would cover you (and not any other members of your fam ily) is more than 9.5% of your household income for the year, or if the c o verage your employer provides does not meet the "minimum value " standard s et by the Affordable Care Act, you may be eligible for a tax c redit. ' Note: If you purchase a health p lan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose t he employer contribution (if any) to the employer- offered coverage. A lso, this employer contribution - as well as your employee contribution to employer- offered coverage- is o ften excluded from income for Federal and State income tax p urposes. Your payments for coverage through the Marketplace are made on an a ftertax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact North East lsd Employee Benefits at The Marketplace can help you evaluate your coverage o ptions, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.oov for more information, including an o n line application for health insurance coverage and cont a c t information for a Health Insurance Marketplace in your area. 1 An emp loyer- sponsored hea lth p lan meets the " m in imum va lue standard " it the p lan ' s share of the tota l a ll owed benef it costs covered by the p lan rs no less than 60 pe rc ent of such costs

4 PART B: Information About Health Coverage Offered by Your Employer T h is section c ontains information about any health coverage offered by your employer. If you decide to complete an application for c o verage in the Marketplace, you w il l be a sked to provide this informatio n. This information is numbered to corres p o nd to t h e Ma rketpla ce appli cation. 3. Employer na me North East ISO 5. Employer ad dre ss 8961 Tesoro Drive, Suite City San Antonio 10. Who can we contact about employee health coverage at this job? North East lsd Employee Benefits 11. Phone number (if different from above) address eb@neisd.net 4. Em player Identification Number (EIN) Employer phone number State Texas 9. ZIP code Here is some basic information about health coverage offered by this employer: A s your e m p loyer, we o ffer a health p lan to : Ill A ll employees. Elig ible employees are: Full-time employees must work at least 32 hours per week Part-time employees must work at least 20 hours per week D So me em p loyees. Eligible employees are: With res p ect to dependents : Ill We do offe r coverage. El igible dependents are: Dependent Eligibility: Spouse and child(ren) under the age of26- for more details see the Summary Plan Description (SPD). D We do n o t offer coverage. GZI If che cke d, th is covera ge meets the m in imum value standard, and the cos t of this coverage to you is intended to b e a ffordable, base d on employee wages. Even if your employer intends your coverage to be affordable, you may still be eligible for a premium d isc o unt th rough th e Marketplace. The Marketplace w ill use your household income, along w ith other factors, t o d e term ine wheth er you may be e ligib le for a premium discount. If, for example, your wages vary from w eek to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly e m p loyed m id - year, or if you have other in come losses, you may s till quali fy for a premium d iscoun t. If you decide to s hop for covera ge in the Marketplace, HealthCare.gov w ill guide you through the process. Here' s the employer inform a tion you ' ll enter when you visit HealthCare.gov to f ind out if you can get a tax credit to lower your monthly prem ium s.

5 8961 TESORO DRIVE SAN ANTONIO, TEXAS IMPORTANT NOTICE OF YOUR RIGHT TO DOCUMENTATION OF HEALTH COVERAGE FEDERAL LAW MAY AFFECT YOUR HEALTH COVERAGE, OR THE COVERAGE OF YOUR DEPENDENTS, IF YOU ARE ENROLLED OR BECOME ELIGIBLE TO ENROLL IN THE NORTH EAST INDEPENDENT SCHOOL DISTRICT (NEISD) HEALTH COVERAGE PLAN DURING THE 2013 Plan YEAR. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was signed into law on August 21, HIPAA impacts group health plans, such as those provided by NEISD, by improving the availability and portability of health coverage. However, HIPAA provides that non-federal governmental plans that are self-funded, such as the plans provided by NEISD, can elect to be exempted from some or all of the main provisions of the Act. NEISD is the plan sponsor of a self-funded, non-federal governmental group health plan that provides medical coverage benefits to employees of NEISD. Currently, NEISD has three separate self-funded health care plans that are administered by Blue Cross Blue Shield of Texas and HMO Blue Texas. Section 102(a) of HIPAA (codified, in pertinent part, at 42 USC 300gg 21), Section of the HIPAA Regulations (45 CFR ), and Section 2721(b)(2) of the Public Health Service Act allow plan sponsors of non-federal governmental health plans to elect to be exempted from the following HIPAA and other requirements: (1) Standards relating to benefits for mothers and newborns; (2) Parity in the application of certain limits to mental health benefits; (3) required coverage for reconstructive surgery following mastectomies; and (4) Coverage of dependent students on a medically necessary leave of absence. Pursuant to such statutory and regulatory provisions, on December 13, 2010, the North East Independent School District elected to be exempted from several of such requirements. On September 10, 2012, the North East Independent School District elected to remain exempted from the same requirements. This notice provides you with information regarding (1) the provisions of HIPAA and the Women s Health and Cancer Rights Act (WHCRA) from which NEISD has elected to be exempted, (2) how the exemption applies to participants under each of the three health coverage plans offered by NEISD, and (3) whether NEISD chooses to provide voluntarily any of the protections required under HIPAA and WHCRA from which NEISD has elected to be exempted, and if so, a list of which protections apply to plan participants. (1) PREXISTING CONDITIONS HIPAA REQUIREMENTS: HIPAA limits the circumstances under which health coverage may be excluded for medical conditions present before you enroll in an NEISD health care plan

6 (i.e., preexisting condition(s)). Under HIPAA, preexisting condition exclusion generally may not be imposed with respect to a participant or dependent unless the following requirements are satisfied: the preexisting condition exclusion must relate to a condition for which medical advice, diagnosis, care or treatment was recommended or received during the six-month period prior to an individual s enrollment date; a preexisting condition exclusion may not last for more than 12 months (18 months for a late enrollee) after an individual s enrollment date; and the 12-month (or 18-month) exclusion period must be reduced by the number of days of the individual s prior creditable coverage, excluding coverage before any break in coverage of 63 days or more. In addition, you are entitled to a certificate that will show evidence of your prior health coverage. Under HIPAA, if you buy health insurance other than through an employer group health plan, a certificate of prior coverage may help you obtain coverage, even if you have a medical condition that would otherwise be considered a preexisting condition. Newborns/Adopted Children/Pregnancy: a health plan may not impose any pre-existing condition exclusion with regard to a dependent child of a plan participant who is covered under any creditable coverage within 31 days of birth, date of adoption, or date of placement for adoption and subsequently enrolls in the health plan without a significant break in coverage. A group health plan may not impose a preexisting condition exclusion relating to pregnancy as a preexisting condition. Preexisting conditions may not be excluded for any child under the age of 19 who is covered under their parent s health plan. NEISD COVERAGE: HMO BLUE TEXAS: The HMO Blue Texas medical plan does not have a preexisting exclusion clause for any condition. BLUE CHOICE LOW OPTION PPO: NEISD complies with state law requirements relating to preexisting conditions that are identical to the HIPAA requirements. NEISD will not impose any preexisting condition exclusion with regard to a child who, as of the last day of the 31-day period beginning with the date of Page 2 of 13

7 birth, is covered under the NEISD plan. Accordingly, if a newborn is enrolled in the NEISD group health plan within 31 days of birth, the NEISD group health plan will not impose any preexisting condition exclusion with regard to the child. Additionally, NEISD will not impose any preexisting condition exclusion for any covered child under the age of 19. BLUE CHOICE HIGH OPTION PPO: NEISD complies with state law requirements relating to preexisting conditions that are identical to the HIPAA requirements. NEISD will not impose any preexisting condition exclusion with regard to a child who, as of the last day of the 31-day period beginning with the date of birth, is covered under the NEISD plan. Accordingly, if a newborn is enrolled in the NEISD group health plan within 31 days of birth, the NEISD group health plan will not impose any preexisting condition exclusion with regard to the child. Additionally, NEISD will not impose any preexisting condition exclusion for any covered child under the age of 19. (2) SPECIAL ENROLLMENT PERIODS FOR INDIVIDUALS (AND CERTAIN DEPENDENT BENEFICIARIES) HIPAA REQUIREMENTS: HIPAA provides that if you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in the health coverage plan, provided that you are otherwise eligible for coverage under terms of the plan and you request enrollment within 31 days from the other coverage ending. HIPAA provides that if you become ineligible for Medicaid or CHIP and lose coverage, or if you become eligible for the State Premium Assistance Program for yourself or your dependents (including your spouse), you may enroll yourself or your dependents in the health coverage plan, provided that you are otherwise eligible for coverage under terms of the plan and you request enrollment within 60 days from the date of the event. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents provided that you request enrollment within 31 days from date of the marriage, birth, adoption, or placement for adoption. Page 3 of 13

8 On or before the time an employee is offered the opportunity to enroll in a group health plan, the plan is required to provide the employee with a description of the plan s special enrollment rules. Effective dates of enrollment: Enrollment is effective with respect to an employee and a dependent who enroll in the plan due to loss of other coverage, not later than the first day of the first calendar month beginning after the date the completed request for enrollment is received. In the case of marriage, enrollment is effective not later than the first day of the first calendar month beginning after the date the completed request for enrollment is received by the plan. In the case of a dependent s birth, enrollment is effective on the date of such birth. In the case of a dependent s adoption, or placement for adoption, enrollment is effective on the date of such adoption or placement for adoption. NEISD COVERAGE: HMO BLUE TEXAS: NEISD complies with HIPAA requirements related to special enrollment periods, as follows: NEISD complies with HIPAA special enrollment periods for individuals (and certain dependents) who are otherwise eligible for coverage under the terms of the plan and who previously declined coverage under the NEISD plan due to other health coverage. NEISD complies with HIPAA special enrollment periods for individuals who become a dependent of a participant through marriage, birth, adoption, or placement for adoption. NEISD complies with HIPAA requirements regarding the effective dates of enrollment for individuals during a special enrollment period. NEISD complies with HIPAA requirements providing for the special enrollment of an employee who is eligible, but not enrolled, for coverage under the terms of the plan and an individual who is a dependent of such employee if the employee would be a participant but for a prior election by the employee not to enroll in the plan during a previous enrollment period, and either (1) the employee and the individual become married; or (2) the employee and the individual are married and a child becomes a dependent of the employee through birth, adoption, or placement for adoption. BLUE CHOICE LOW OPTION PPO: NEISD complies with HIPAA s requirements related to special enrollment periods, as follows: NEISD complies with HIPAA special enrollment periods for individuals (and certain dependents) who are otherwise eligible for coverage under the terms of the plan and who previously declined coverage under the NEISD plan due Page 4 of 13

9 to other health coverage. NEISD complies with HIPAA special enrollment periods for individuals who become a dependent of a participant through marriage, birth, adoption, or placement for adoption. NEISD complies with HIPAA requirements regarding the effective dates of enrollment for individuals during a special enrollment period. NEISD complies with HIPAA requirements providing for the special enrollment of an employee who is eligible, but not enrolled, for coverage under the terms of the plan and an individual who is a dependent of such employee if the employee would be a participant but for a prior election by the employee not to enroll in the plan during a previous enrollment period, and either (1) the employee and the individual become married; or (2) the employee and the individual are married and a child becomes a dependent of the employee through birth, adoption, or placement for adoption. BLUE CHOICE HIGH OPTION PPO: NEISD complies with HIPAA s requirements related to special enrollment periods, as follows: NEISD complies with HIPAA special enrollment periods for individuals (and certain dependents) who are otherwise eligible for coverage under the terms of the plan and who previously declined coverage under the NEISD plan due to other health coverage. NEISD complies with HIPAA special enrollment periods for individuals who become a dependent of a participant through marriage, birth, adoption, or placement for adoption. NEISD complies with HIPAA requirements regarding the effective dates of enrollment for individuals during a special enrollment period. NEISD complies with HIPAA requirements providing for the special enrollment of an employee who is eligible, but not enrolled, for coverage under the terms of the plan and an individual who is a dependent of such employee if the employee would be a participant but for a prior election by the employee not to enroll in the plan during a previous enrollment period, and either (1) the employee and the individual become married; or (2) the employee and the individual are married and a child becomes a dependent of the employee through birth, adoption, or placement for adoption. (3) PROHIBITIONS AGAINST DISCRIMINATING AGAINST INDIVIDUAL PARTICIPANTS AND BENEFICIARIES HIPAA REQUIREMENTS: Page 5 of 13

10 A group health plan may not establish rules for eligibility in the health plan (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the following health status-related factors in relation to the individual or a dependent of the individual: (1) health status; (2) medical condition (including both physical and mental illnesses); (3) claims experience; (4) receipt of health care; (5) medical history; (6) genetic information; (7) evidence of insurability (including conditions arising out of acts of domestic violence); (8) disability. NEISD ELECTION/COVERAGE: HMO BLUE TEXAS: NEISD complies with HIPAA s requirements prohibiting discrimination against participants and beneficiaries. BLUE CHOICE LOW OPTION PPO: NEISD complies with HIPAA s requirements prohibiting discrimination against participants and beneficiaries. BLUE CHOICE HIGH OPTION PPO: NEISD complies with HIPAA s requirements prohibiting discrimination against participants and beneficiaries. (4) STANDARDS RELATING TO BENEFITS FOR MOTHERS AND NEWBORNS HIPAA REQUIREMENTS: A group health plan may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child, following a normal vaginal delivery, to less than 48 hours, or restrict benefits for any hospital length of stay in connection with childbirth for the mother of a newborn child, following a cesarean section, to less than 96 hours, or require that a provider obtain authorization from the plan for prescribing any length of stay required. This section does not apply in any case in which the decision to discharge the mother or her newborn child prior to the expiration of the minimum length of stay otherwise required is made by an attending provider in consultation with the mother. A group health plan may not (1) deny to the mother or her newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; (2) provide monetary payments or rebates to the mother to encourage such mothers to accept less than the minimum protections available; (3) penalize or otherwise reduce or limit the reimbursement of an attending provider because such Page 6 of 13

11 provider provided care to an individual participant or beneficiary; (4) provide incentives (monetary or otherwise) to an attending provider to induce such provider to provide care to an individual participant or beneficiary; or (5) restrict benefits for any portion of a period within a required hospital length of stay in a manner which is less favorable than the benefits provided for any preceding portion of such stay. However, a group health plan is not prevented from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or newborn child under the plan, except that such coinsurance or other cost-sharing for any portion of a period within a required length of hospital stay may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay. NEISD ELECTION/COVERAGE: HMO BLUE TEXAS: NEISD has elected to be exempted from HIPAA requirements prohibiting restriction of the period of hospitalization after birth for which benefits are payable to less than 48 hours for a vaginal delivery and 96 hours for a cesarean delivery. However, NEISD has elected to voluntarily comply with some of HIPAA s requirements related to hospitalization in connection with childbirth, as follows: NEISD has elected to voluntarily comply with HIPAA requirements prohibiting restriction of the period of hospitalization after birth for which benefits are payable to less than 48 hours for a vaginal delivery and 96 hours for a cesarean delivery, unless the attending health care provider, in consultation with the mother, decides that an earlier discharge is appropriate. In addition, NEISD will not (1) deny to the mother of her newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; (2) provide monetary payments or rebates to the mother to encourage such mothers to accept less than the minimum protections available; (3) penalize or otherwise reduce or limit the reimbursement of an attending provider because such provider provided care to an individual participant or beneficiary; (4) provide incentives (monetary or otherwise) to an attending provider to induce such provider to provide care to an individual participant or beneficiary; or (5) restrict benefits for any portion of a period within a required hospital length of stay in a manner which is less favorable than the benefits provided for any preceding portion of such stay. NEISD will apply deductibles and coinsurance requirements as stated in the summary plan document for any inpatient hospital services. BLUE CHOICE LOW OPTION PPO: Page 7 of 13

12 NEISD has elected to be exempted from HIPAA requirements prohibiting restriction of the period of hospitalization after birth for which benefits are payable to less than 48 hours for a vaginal delivery and 96 hours for a cesarean delivery. However, NEISD has elected to voluntarily comply with some of HIPAA s requirements related to hospitalization in connection with childbirth, as follows: NEISD has elected to voluntarily comply with HIPAA requirements prohibiting restriction of the period of hospitalization after birth for which benefits are payable to less than 48 hours for a vaginal delivery and 96 hours for a cesarean delivery, unless the attending health care provider, in consultation with the mother, decides that an earlier discharge is appropriate. In addition, NEISD will not (1) deny to the mother of her newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; (2) provide monetary payments or rebates to the mother to encourage such mothers to accept less than the minimum protections available; (3) penalize or otherwise reduce or limit the reimbursement of an attending provider because such provider provided care to an individual participant or beneficiary; (4) provide incentives (monetary or otherwise) to an attending provider to induce such provider to provide care to an individual participant or beneficiary; or (5) restrict benefits for any portion of a period within a required hospital length of stay in a manner which is less favorable than the benefits provided for any preceding portion of such stay. NEISD will apply deductibles and coinsurance requirements as stated in the summary plan document for any inpatient hospital services. BLUE CHOICE HIGH OPTION PPO: NEISD has elected to be exempted from HIPAA requirements prohibiting restriction of the period of hospitalization after birth for which benefits are payable to less than 48 hours for a vaginal delivery and 96 hours for a cesarean delivery. However, NEISD has elected to voluntarily comply with some of HIPAA s requirements related to hospitalization in connection with childbirth, as follows: NEISD has elected to voluntarily comply with HIPAA requirements prohibiting restriction of the period of hospitalization after birth for which benefits are payable to less than 48 hours for a vaginal delivery and 96 hours for a cesarean delivery, unless the attending health care provider, in consultation with the mother, decides that an earlier discharge is appropriate. In addition, NEISD will not (1) deny to the mother of her newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of this section; (2) provide monetary payments or rebates to the mother to encourage such mothers to accept less than the minimum protections available; (3) penalize or otherwise reduce or limit the reimbursement of an attending provider Page 8 of 13

13 because such provider provided care to an individual participant or beneficiary; (4) provide incentives (monetary or otherwise) to an attending provider to induce such provider to provide care to an individual participant or beneficiary; or (5) restrict benefits for any portion of a period within a required hospital length of stay in a manner which is less favorable than the benefits provided for any preceding portion of such stay. NEISD will apply deductibles and coinsurance requirements as stated in the summary plan document for any inpatient hospital services. (5) PARITY IN THE APPLICATION OF CERTAIN LIMITS TO MENTAL HEALTH BENEFITS HIPAA REQUIREMENTS: A group health plan must treat mental health benefits no differently than medical and surgical benefits with respect to a plan s application of aggregate lifetime dollar limits, and annual dollar limits. HIPAA does not require a group health plan to provide mental health benefits; nor does it affect the terms and conditions (for example, cost sharing, limits on days of coverage, requirements regarding medical necessity, requirements that patients or providers obtain prior authorization for treatment, and requirements relating to primary care physicians referrals for treatment) regarding the amount, duration, or scope of the mental health benefits, except as specifically provided in regard to parity of aggregate lifetime dollar limits and annual dollar limits. NEISD ELECTION/COVERAGE: HMO BLUE TEXAS: NEISD has elected to be exempted from HIPAA requirements prohibiting the treatment of mental health benefits differently than medical and surgical benefits with respect to the plan s lifetime or annual limitation. However, NEISD has elected to voluntarily comply with some of HIPAA s requirements that mental health benefits be treated no differently than medical and surgical benefits with respect to a plan s lifetime or annual limitation, as follows: NEISD has elected to voluntarily comply with HIPAA requirements that mental health benefits will be treated no differently than medical and surgical benefits with respect to a plan s lifetime or annual limitation, which currently has no lifetime maximum limit. The group health plan will place limitations in regard to the terms and conditions of the coverage, such as preauthorization requirements, and co-payments. BLUE CHOICE LOW OPTION PPO: NEISD has elected to be exempted from HIPAA requirements prohibiting the treatment of mental health benefits differently than Page 9 of 13

14 medical and surgical benefits with respect to the plan s lifetime or annual limitation. However, NEISD has elected to voluntarily comply with some of HIPAA s requirements that mental health benefits be treated no differently than medical and surgical benefits with respect to a plan s lifetime or annual limitation, as follows: NEISD has elected to voluntarily comply with HIPAA requirements that mental health benefits will be treated no differently than medical and surgical benefits with respect to a plan s lifetime or annual limitation, which currently has no lifetime maximum limit. The group health plan will place limitations in regard to the terms and conditions of the coverage, such as preauthorization requirements, and co-payments. BLUE CHOICE HIGH OPTION PPO: NEISD has elected to be exempted from HIPAA requirements prohibiting the treatment of mental health benefits differently than medical and surgical benefits with respect to the plan s lifetime or annual limitation. However, NEISD has elected to voluntarily comply with some of HIPAA s requirements that mental health benefits be treated no differently than medical and surgical benefits with respect to a plan s lifetime or annual limitation, as follows: NEISD has elected to voluntarily comply with HIPAA requirements that mental health benefits will be treated no differently than medical and surgical benefits with respect to a plan s lifetime or annual limitation, which currently has no lifetime maximum limit. The group health plan will place limitations in regard to the terms and conditions of the coverage, such as preauthorization requirements, and co-payments. (6) REQUIRED COVERAGE FOR RECONSTRUCTIVE SURGERY FOLLOWING MASTECTOMIES WHCRA REQUIREMENTS: In the case of a covered person receiving benefits under their plan in connection with a mastectomy and who elects breast reconstruction, coverage will be provided in a manner determined in consultation with the attending physician and the patient for: (i) reconstruction of the breast on which the mastectomy was performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iii) prostheses and treatment of physical complications at all stages of the mastectomy, including lymph edemas. Deductibles, co-insurance, and co-payment amounts will be the same as those applied to the other similarly covered medical services, such as surgery and prostheses. NEISD ELECTION/COVERAGE: Page 10 of 13

15 HMO BLUE TEXAS: NEISD has elected to be exempted from the WHCRA requirements related to required coverage for reconstructive surgery following mastectomies. However, NEISD has elected to voluntarily comply with some of the WHCRA requirements related to such coverage as follows: NEISD has elected to voluntarily comply with some of the WHCRA requirements relating to reconstructive surgery following mastectomies. In the case of a covered person receiving benefits under the plan in connection with a mastectomy and who elects breast reconstruction, coverage will be provided in a manner determined in consultation with the attending physician and the patient for (i) reconstruction of the breast on which the mastectomy was performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iii) prostheses and treatment of certain physical complications related to the mastectomy, including lymph edemas. Deductibles, co-insurance, and co-payment amounts will be the same as those applied to other similarly covered medical services, such as surgery and prostheses. BLUE CHOICE LOW OPTION PPO: NEISD has elected to be exempted from the WHCRA requirements related to required coverage for reconstructive surgery following mastectomies. However, NEISD has elected to voluntarily comply with some of the WHCRA requirements related to such coverage as follows: NEISD has elected to voluntarily comply with some of the WHCRA requirements relating to reconstructive surgery following mastectomies. In the case of a covered person receiving benefits under the plan in connection with a mastectomy and who elects breast reconstruction, coverage will be provided in a manner determined in consultation with the attending physician and the patient for (i) reconstruction of the breast on which the mastectomy was performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iii) prostheses and treatment of certain physical complications related to the mastectomy, including lymph edemas. Deductibles, co-insurance, and co-payment amounts will be the same as those applied to other similarly covered medical services, such as surgery and prostheses. BLUE CHOICE HIGH OPTION PPO: NEISD has elected to be exempted from the WHCRA requirements related to required coverage for reconstructive surgery following mastectomies. However, NEISD has elected to voluntarily comply with some of the WHCRA requirements related to such coverage as follows: NEISD has elected to voluntarily comply with some of the WHCRA requirements relating to reconstructive surgery following mastectomies. In Page 11 of 13

16 the case of a covered person receiving benefits under the plan in connection with a mastectomy and who elects breast reconstruction, coverage will be provided in a manner determined in consultation with the attending physician and the patient for (i) reconstruction of the breast on which the mastectomy was performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (iii) prostheses and treatment of certain physical complications related to the mastectomy, including lymph edemas. Deductibles, co-insurance, and co-payment amounts will be the same as those applied to other similarly covered medical services, such as surgery and prostheses. ADDITIONAL INFORMATION FOR PLAN PARTICIPANTS: The NEISD group health plans are required by federal law to furnish certificates of creditable coverage to plan participants in accordance with 45 CFR You have the right to receive a certificate of prior health care coverage since July 1, Should you leave NEISD and obtain employment elsewhere, check with your new plan administrator to see if your new plan excludes coverage for preexisting conditions and if you need to provide a certificate or other documentation of your previous coverage. To obtain a certificate, complete the attached form and return it to the NEISD Employee Benefits Office at the address listed on the form. All information contained in this notice concerning NEISD s voluntary compliance with HIPAA requirements is subject to the summary plan descriptions for each medical plan offered by NEISD and its third party administrator, Blue Cross Blue Shield of Texas. You should read and consult your schedule of benefits to determine the specific benefits/requirements of your health care plan. You may obtain additional information or address questions to: Risk Management and Employee Benefits 8961 Tesoro Drive, Suite 209 San Antonio, Texas (210) Fax: (210) Additional information concerning the administration of your health care plan may be addressed to: Blue Cross Blue Shield of Texas Page 12 of 13

17 Customer Service Help line Or HMO Blue Texas Customer Service Help line Page 13 of 13

18 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR LEGAL DUTIES We are required by law to reasonably safeguard the privacy of your protected health information. We are also required to give you this notice about our legal duties and privacy practices relating to protected health information. Protected health information is any individually identifiable health information, whether oral or recorded in any medium, that is created or received by entities such as health care providers, or health plans, and relates to the physical or mental health or condition of an individual, or to the payment for the provision of health care to an individual and that is maintained in a designated record set(s). We are required to abide by the terms of this notice currently in effect. We reserve the right to change our privacy practices and the terms of this notice for all protected health information we maintain even if it was created or received before issuing the revised notice. If a material revision is made, we will distribute a copy of the revised notice. This notice takes effect on September 23, 2013, and remains in effect until we replace it. You may request a copy of this notice at any time or you may view it by visiting Risk Management s web site at For more information about our privacy practices, or for additional copies of this notice, please contact the individual designated at the end of this notice. USES AND DISCLOSURES We may use and disclose your health information for treatment, payment, and healthcare operations. For example: Treatment: We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related services with a physician or other health care provider. Payment: We may use and disclose your protected health information to determine and to fulfill coverage responsibilities and to provide benefits under the District s health plan. We may also use and disclose your protected health information to obtain or provide reimbursement for benefits provided. Health Care Operations: We may use and disclose your protected health information for certain administrative, financial, legal, and quality improvement activities necessary to run our business and to support the core functions of treatment and payment. Such activities include, but are not limited to, underwriting and other activities relating to the creation, renewal, or replacement of a contract for health benefits. Such activities also include sharing your protected health information with third party business associates that perform various activities for us. In addition to treatment, payment, and health care operations purposes, we may use or disclose your protected health information for the following purposes: Organ and Tissue Donation: If you are an organ donor, we may release your protected health information after your death to organizations that handle organ procurement or organ, eye, or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Family and Representatives: We must disclose your protected health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend, or other person to the extent necessary for the proper provision or payment of healthcare. Persons Involved in Your Care: We may use or disclose protected health information to notify, or assist in the notification of (including identifying or locating) a family member, a personal representative of the individual, or another person responsible for the care of the individual of the individual s location, general condition, or death. If you are present you will have the opportunity to object to such use or disclosure of your protected health information. If you are not present, or the opportunity to agree or object cannot be provided due to incapacity or emergency, we, in the exercise of professional judgment, may determine whether the disclosure is in your best interest. We may use professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to act on your behalf to pick up protected health information. Required by Law: We may use or disclose protected health information to the extent that such use or disclosure is required by federal, state, or local law and the use or disclosure complies with, and is limited to, the relevant requirements of such law. Public Health Activities and Related Purposes: We may disclose your protected health information to public health authorities authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, disability, or child abuse or neglect. We may also disclose your protected health information to a person subject to the jurisdiction of the Food and Drug Administration (FDA) with respect to an FDA-regulated product or activity for which that person has certain responsibilities.

19 Abuse or Neglect: We may disclose protected health information about an individual whom we reasonably believe to be a victim of abuse, neglect, or domestic violence to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence. Health Oversight Activities: With certain exceptions, we may disclose your protected health information to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight of specified programs. Judicial and Administrative Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding: 1) in response to an order of a court or administrative tribunal, or 2) in response to a subpoena, discovery request, or other lawful process. Law Enforcement Purposes: We may disclose your protected health information for a law enforcement purpose to a law enforcement official as required or permitted by law. Workers Compensation: We may disclose protected health information as authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs that provide benefits for workrelated injuries or illness without regard to fault. Health and Safety: We may, consistent with applicable law and standards of ethical conduct, use or disclose protected health information, if we, in good faith, believe the use or disclosure will avert a serious threat to health or safety of a person or the public. Plan Sponsor: We may disclose your protected health information to District officials as needed to fulfill operational responsibilities relating to the District s Health Care Plan. National Security: We may use and disclose the protected health information of individuals who are Armed Forces personnel for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission, if the appropriate military authority has published by notice the appropriate information. We may also disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody of an inmate or other individual protected health information about such inmate or individual upon a showing of necessity. SECURITY BREACH If we learn of or otherwise discover that a breach of security has occurred that threatens your unsecured protected health information, then we will notify you in writing without any unreasonable delay, or in any case, no later than sixty (60) days after our discovery of the breach. Our written notice to you shall include a brief description of what events occurred that led to the breach, what type of information was involved, guidance on what you can do to protect yourself, what we are doing to investigate the breach, and contact information for you. If the breach in question affects more than 500 persons, we will also alert local prominent media outlets, although we will not give them any information on any specific individual, including you. We will also notify the Secretary of the Department of Health and Human Services of breaches within the applicable time limits set forth by law. We also require that any entities with whom we contract with as Business Associates who perform services for us to notify us of any breach of information. Should such a breach occur we will notify you in accordance with the terms of this paragraph. INDIVIDUAL RIGHTS Access: You have a right of access to inspect and obtain a copy of protected health information about you, with limited exceptions, for so long as we maintain the information. You may request the information in a format other than hard copies and we will comply with your request if practicable. You must make your written request for a copy to the contact person listed at the end of this notice. You will be charged a reasonable cost-based fee for expenses such as copies, labor, postage, and a summary of the health information if you request one. You may also request access by sending written notice to the contact person at the end of this notice. You have a right to request a review of certain denials of access. Restriction: You have the right to request additional restrictions on the use and disclosure of your protected health information. We are not required to agree, but if we do, we are required to abide by any agreed upon restriction. We must also accommodate reasonable written requests to receive communications of protected health information by alternative means or at alternative locations, if you clearly state that the disclosure of all or part of that information could endanger you. Amendment: You have the right to request that we amend your protected health information. Your request must be in writing stating the reason for your request and must be provided to the contact person listed at the end of this notice. We have the right to deny such requests under certain circumstances. If your request is denied, you have a right to submit a written statement disagreeing with the denial. Accounting: You have a right to receive an accounting of disclosures of your protected health information made by us or our business associates for purposes other than treatment, payment or health care operations, and certain other