Solutions. Employee Health Plan. Solutions.

Transcription

1 Solutions. Employee Health Plan Solutions. Piedmont Community Services Effective April 1, 2009

2 Solutions. Piedmont Community Services The NEW Third Party Administrator of the medical plan of Piedmont Community Services will be Primary PhysicianCare, Inc. (Primary). Primary handles administrative services such as claims processing, customer service, and provider relations. Piedmont Community Services will use the Gateway Health Alliance network (Gateway) with additional access to providers through the Primary PhysicianCare network and the Beech Street network. You can access the Provider Directory on-line at and to check for participating physicians. Gateway Health Alliance (Gateway) will now manage your prior authorizations and case management. A Prior authorization list is included with your Health Plan information. Please contact the Gateway Medical Management team of nurses at the pre-certification phone number below if you have any pending surgeries or procedures. Express Scripts will be your new prescription benefit manager. Below is a phone number to call with prescription questions. You will be receiving your new medical/prescription drug card before your effective date. Please be sure to provide your new ID card to ALL of your providers and have them make a copy for your file. If you have any questions, or if you have problems at your providers office, please contact us at the Customer Service number below. **For existing RETAIL prescriptions, effective 4/1/09 please give the pharmacy your new medical card to obtain a refill. For MAIL ORDER, to have your medication on hand until your mail order arrives, you will need to either 1) if possible go ahead and obtain a refill prior to 4/1/09 OR 2) obtain two new written prescriptions from your physician to submit one for instant fill at retail, and another to mail into Express Scripts. ** Pre-certification: Customer Service: , then follow prompts for customer service. To help route your call quickly, please have your ID number (from your ID card) ready when you call. Express Scripts:

3 Solutions. Piedmont Community Services - Benefit Summary PPO 500 Plan Service In Network Out of Network Annual Deductible Individual Family $500 $1,000 $750 $1,500 PCP Specialist & Urgent Care Office Visits Office Surgery, Diagnostics Tests, Lab & X-ray Diagnostic Tests Charges for outpatient independent lab, including diagnostic testing and x-rays referred by physicians for illnesses not otherwise outlined in the Schedule of Benefits 100% after $25 co-pay per visit Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 60% after deductible Plan pays 60% after deductible Preventive Care / Wellness Well Child Exams through age 6 Immunizations, Lab & X-ray Preventative Care(Age 7+ and Adults) (Gyn Exam) Mammogram screening (one annually) Prostate Screening, Rectal Exam $25 co-pay not subject to deductible Plan pays 80% deductible waived Plan pays 100% deductible waived Plan pays 100% deductible waived Plan pays 100% deductible waived Plan pays 100% deductible waived Emergency Care Facility & ER Physician charges Plan pays 80% after in-network deductible Ambulance ($1,500 calendar year llimit ground ambulance) Plan pays 80% after in-network deductible Inpatient & Outpatient Hospital Services Plan pays 80% after deductible Plan pays 60% after deductible Maternity Includes Pre-natal and post-natal follow-up care And Delivery Plan pays 80% after deductible Plan pays 60% after deductible Outpatient Prescription Drug ($3,500 per member out of pocket maximum) Co-pay per 31-day supply retail pharmacy Co-pay per 90-day supply, Home Delivery Pharmacy 31 Day Supply, retail pharmacy: 90-day supply, Mail Order Pharmacy: Generic: $15 Generic: $30 Formulary Brand: $30 Formulary Brand: $60 Non-FormularyBrand: $60 or 20% coinsurance with $200 max per prescription Non-Formulary: $120 or 20% coinsurance with a $400 max per prescription Out of Pocket Maximum Individual Family $2,500 $5,000 $3,750 $7,500 Lifetime Maximum $1,000,000 2

4 Solutions. Piedmont Community Services - Benefit Summary PPO 2,000 Plan Service In Network Out of Network Annual Deductible Individual Family $2,000 $4,000 $3,000 $6,000 PCP Specialist & Urgent Care Office Visits Office Surgery, Diagnostics Tests, Lab & X-ray 100% after $30 co-pay per visit Plan pays 80% after deductible Plan pays 60% after deductible Diagnostic Tests Charges for outpatient independent lab, including diagnostic testing and x-rays referred by physicians for illnesses not otherwise outlined in the Schedule of Benefits Preventive Care / Wellness Well Child Exams Immunizations Preventative Care(Age 7+ and Adults) (Gyn Exam) Mammogram screenings (one annually) Prostate Screening, Rectal Exam Plan pays 100% up to CYM of $250 then 80% after deductible $30 co-pay not subject to deductible Plan pays 80% after in-network deductible Plan pays 100% deductible waived Plan pays 100% deductible waived Plan pays 100% deductible waived Plan pays 100% deductible waived Plan pays 60% after deductible Emergency Care Facility & ER Physician charges Ambulance ($1,500 calendar year llimit ground ambulance) Plan pays 80% after in-network deductible Plan pays 80% after in-network deductible Inpatient & Outpatient Hospital Services Plan pays 80% after deductible Plan pays 60% after deductible Maternity Includes Pre-natal and Post-natal follow-up care And Delivery Plan pays 80% after deductible Plan pays 60% after deductible Outpatient Prescription Drug ($3,500 per member out of pocket maximum) Co-pay per 31-day supply retail pharmacy Co-pay per 90-day supply, Home Delivery Pharmacy 31 Day Supply, retail pharmacy: 90-day supply, Home Delivery Pharmacy: Generic: $15 Generic: $30 Formulary Brand: $30 Formulary Brand: $60 Non-Formulary Brand: $60 or 20% coinsurance with $200 max per prescription Non-Formulary: $120 or 20% coinsurance with a $400 max per prescription Out of Pocket Maximum Individual Family $4,000 $8,000 $6,000 $12,000 Lifetime Maximum $1,000,000 3

5 Solutions. Becoming a Good Healthcare Consumer at Piedmont Community Services: Don t use a Specialist or Emergency Room for basic healthcare. Only use the Emergency Room for true emergencies. Use generic drugs whenever possible; ask your doctor to prescribe a generic first! Participate in the Healthy Solutions Wellness Program (more details coming soon) A SK QUESTIONS! You may call Customer Service at Primary PhysicianCare, Inc. to inquire about your benefits or claim status at , and then follow the prompts for customer service. To help route your call quickly, please have your ID number (from your ID card) ready when you call. 4

6 Solutions. Services Requiring Preauthorization / Notification Preauthorization / Notification Phone # (877) **48 Hour Advance Notice Is Required for Preauthorization of Services** ** Authorization required within 48 hours after Emergency Room Admission ** Angioplasty Cardiac Cath Cardiac/Pulmonary Rehabilitation Congenital Heart Disease Dialysis Durable Medical Equipment ($500) Endoscopies / Bronchoscopy / Colonoscopy / Sigmoidoscopy (if performed in the hospital) Home Health Care / Home Health Services / Hospice Inpatient Hospital Care / Inpatient Mental Health Inpatient Rehabilitation Non-Emergent Ambulance Transportation- Non reimbursable except hospital to hospital or with appropriate letter of medical necessity. Oncology / Chemotherapy / Radiation Therapy Outpatient Pain Management Services Outpatient Surgery (Hospital or Freestanding surgical center) PET Scans Pregnancy / Maternity Care (at time of diagnosis of pregnancy) Skilled Nursing Facility Admissions Transplants including Evaluations Any services performed by a non-participating provider that cannot be performed by a network provider 5

7 Solutions. Take control. Want to take control of your health? Ask about Healthy Solutions. Healthy Solutions by Gateway Health Alliance, Inc. SM Free benefit offered by Piedmont Community Services Health Fair with screenings, information At risk employees partner with your own personal nurse health coach Health information kept strictly confidential according to HIPAA regulations More information to come! 6

8 Solutions. When to Contact Gateway Health Alliance extension 2 To obtain preauthorization for a test or procedure. Questions about Wellness Program, Healthy Solutions With Case Management, Utilization Review, Disease Management and Maternity Management questions. When to Contact Primary PhysicianCare, Inc To report a lost or stolen ID Card, and request a new one. To verify benefits for a treatment or service. prior authorization is required. For treatment or service tentatively scheduled, to advise if To find out if a provider or facility is considered in-network. Will you have deductible or out-of-pocket/coinsurance requirements for a treatment or service being considered? Has your claim been received? Has your claim been paid? 7

9 Solutions. Contacting Primary PhysicianCare Inc. Piedmont Community Services Customer Service Representatives are available for you for inquiries about your health benefit plan or claim status. HOURS ARE: 8:00am - 7:00pm EST Please leave messages after hours. BY PHONE then follow the prompts for customer service. ONLINE then follow the prompts for registration. BY MAIL Primary PhysicianCare, Inc. P.O. Box Charlotte, NC IMPORTANT INFORMATION TO HAVE READY your ID number (from ID card) your group number or Employer name the date of service 8

10 Solutions. Tips on How To Get Your Claim Processed Quickly And Correctly 1. For college students: always, every semester, submit a letter from the college registrar or a copy of your financial statement from the college or university showing full time student status. If not received, claims will be pended and we will write you requesting the information. 2. Accident Information: for each claim that is an accident, please include how, when and where the accident occurred. For chiropractic claims with the diagnosis of back pain, we will also need to know how when and where the injury occurred to rule out that it could be the result of an accident. 3. When you have other coverage: for children or spouse s claims, the process can be expedited with other coverage information attached or sent in separately on a claim form. Without this information, we will pend claim and request information, which will slow down the processing. 4. Medical Supplies: please ask doctor to include a letter of medical necessity when prescribing medical equipment and supplies. Send all correspondence to: Primary PhysicianCare Inc. P.O. Box Charlotte, NC Customer Service: then follow the prompts for customer service. To help route your call quickly, please have your ID number (from your ID card) ready when you call. 9

11 Solutions. Health Plan Enrichments 1. Healthy Solutions by Gateway Health Alliance, Inc. SM Piedmont Community Services promotes and encourages wellness. Gateway s Healthy Solutions program helps educate members about lifestyles, healthy choices, exercise, and how to remain healthy. If you have one of the following conditions, please call our wellness nurses at , option 5 for free information and possibly enhanced benefits: Asthma Congestive Heart Failure Diabetes Hypertension Overweight 2. Liberty Diabetic (formerly National Diabetic Pharmacy) Special coverage for insulin and diabetic supplies obtained from Liberty Medical for members enrolled in the disease management program include: 1. Diabetic supplies ordered from Liberty are covered at 100% with no co-payment. Supplies include blood glucose monitors, lancet devices, blood glucose strips, urine test strips, control solution, blood glucose monitor batteries, alcohol preps, lancets, syringes and supplies; 2. A 90-day supply of insulin for a maximum of 2 generic co-payments. 3. Insulin pumps are covered at 80%, deductible waived. 3. Education Benefits Charges for Educational Benefits will be covered as explained in the Schedule of Benefits with the following limitations: Diabetic Education, to a lifetime maximum of 10 sessions and $750.00; Congestive Heart Failure Education, to a lifetime maximum of 5 sessions and $250; Asthma Education, to a lifetime maximum of 5 sessions and $250; Lactation and Well Baby Education, to a maximum of 6 sessions and $ Baby Plus Maternity Management New benefit offered through your employer at no cost to you! Access to specially trained maternity management nurse. Informative prenatal educational materials. Comprehensive Risk Assessment. Rewards for participation! 10

12 Piedmont Community Services Employee Monthly Contributions Wellness Program Participants Rates Monthly Employee Contribution Tier PPO 500 PPO 2000 Employee $ $61.94 Employee / Child $ $ Employee / Children $ $ Employee / Spouse $ $ Employee / Family $1, $1, Wellness Program Non-Participants Rates (effective May 1, 2009) Monthly Employee Contribution Tier PPO 500 PPO 2000 Employee $ $81.94 Employee / Child $ $ Employee / Children $ $ Employee / Spouse $ $ Employee / Family $1, $1, **Above rates are after deduction of employer paid portion, these are the actual employee portion of premium**

13 Piedmont Community Services Employee Monthly Contributions Optional Vision Benefit Monthly Employee Contribution Tier Vision Employee Employee / Child Employee / Children Employee / Spouse Employee / Family Vision Plan No Network Restrictions Deductible $0 Vision Exam One Per Plan Year Glasses/Contacts Plan Year Maximum Contact Lenses, Glasses, Frames $20 Co-pay $200

14 P.O. Box Charlotte, NC Enrollment Form Eligibility Fax: Plan Option: (Please check) PLAN 500 PLAN 2000 Effective Date: New Change Explain: Piedmont Community Services Open Enrollment Company Name (Employer) Division/Branch/Plant Employee s Name (Last, First, M.I.) Date Employed Mo Day Yr Address Res. # Bus. # City, State, Zip Marital Status Single Married Divorced Legally Separated Please check each coverage option that is offered by your employer. Coverage Election Medical Vision Employee Spouse Children SIGN HERE ONLY IF YOU WISH TO WAIVE INSURANCE COVERAGE I DO NOT WANT COVERAGE at this time and understand that I may be denied coverage at a later date if I then decide to apply. Employee s Signature Date ELIGIBILTY THIS SECTION MUST BE COMPLETED Employee (Last, First, M.I.) Social Security Number Spouse (Last, First, M.I.) Social Security Number Date of Birth Mo Day Yr Date of Marriage Date of Birth Mo Day #1 Dependent (Last, First, M.I.) Relationship to Employee Social Security Number Yr Date of Birth Mo Day Yr #2 Dependent (Last, First, M.I.) Relationship to Employee Social Security Number Date of Birth Mo Day #3 Dependent (Last, First, M.I.) Relationship to Employee Social Security Number Yr Date of Birth Mo Day Yr Sex Sex Sex Sex Sex Does any other health insurance, supplemental policy, Medicaid, or Medicare cover this dependent? Yes No Name of Insurance Policy # Does any other health insurance, supplemental policy, Medicaid, or Medicare cover this dependent? Yes No Name of Insurance Policy # Does any other health insurance, supplemental policy, Medicaid, or Medicare cover this dependent? Yes No Name of Insurance Policy # Does any other health insurance, supplemental policy, Medicaid, or Medicare cover this dependent? Yes No Name of Insurance Policy # Does any other health insurance, supplemental policy, Medicaid, or Medicare cover this dependent? Yes No Name of Insurance Policy # I hereby request coverage under my Employer s Health Plan and authorize my employer to deduct from my earnings any required contributions. I have a regularly scheduled work week with the employer named above at least equal to the minimum required for eligibility under the Plan. I hereby authorize all doctors and institutions that have treated or examined me or any of my dependents to release medical records and information to Primary PhysicianCare if requested. Employee s Signature Date

15 Release of Medical Information By signing this form, I authorize my physician, medical professional, hospital, clinic, or other medically related facility, insurance company, or other organization, institution or person, that has any records or knowledge of me or my health, or my dependents or their health, to give such information to Primary PhysicianCare, Inc., if requested. Notice of Enrollment Rights If you are declining enrollment for yourself or your dependents, (including your spouse) because of other health benefit plan coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. If you do not enroll for yourself or your dependents within 30 days after your coverage ends, you may enroll as a Late Enrollee and will be subject to an eighteen (18) month waiting period before coverage can begin. 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 30 days after the marriage, birth, adoption, or placement for adoption. Health Insurance Portability and Accountability Act of 1996 (HIPAA) This group health plan imposes a twelve (12) month pre-existing condition exclusion on your coverage. The pre-existing condition exclusion delays coverage for a medical or mental condition for which you sought medical advice, diagnosis or care, had treatment recommended or received treatment during the six months immediately prior to our enrollment date. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the pre-existing condition exclusion may be reduced by the amount of time you had health coverage prior to your current enrollment, if the lapse of coverage was less than 64 days. The period of coverage is shown on the Certificate of Coverage that is available from your previous plan or company. If you had prior coverage, obtain a Certificate of Coverage from your prior carrier and submit to: Primary PhysicianCare, Inc. Eligibility Department PO Box Charlotte, NC

16 COBRA Notification This notice is intended to inform you, in a summary fashion, of your rights and obligations under the Consolidated Omnibus Budget Reconciliation Act of Federal law gives Qualified Beneficiaries, (An employee, spouse, and/or dependent child currently covered under the group health and/or dental plan on the day before a Qualifying Event ) the right to continue their health care benefits beyond the date that coverage might otherwise terminate. You do not have to show that you are insurable to choose continuation coverage. A Qualified Beneficiary has the same rights under the group health plan as a similarly situated active employee. If the Qualified Beneficiary is deemed legally incapacitated during or prior to the election period, the election period must be suspended until the person is no longer incapacitated, or has a legal guardian appointed, or in the event of death, has an executor of the estate appointed. The entire premium, plus the administration fee allowed by law, must be paid by the continuing person. Coverage will end if the covered individual fails to make timely payment of a contribution or premium within a maximum of 45 days during initial premium/contribution and 30 days thereafter. Benefits Affected by COBRA Any COBRA continuance option must include the offering of benefits for which the person was covered just prior to the COBRA Qualifying Event (an event which qualifies a person for continued coverage under COBRA). A child born to or placed for adoption with the covered employee during the period of COBRA coverage must also be offered these benefits. Dental benefits, vision care benefits, and flexible spending accounts under section 125 plans, or cafeteria-type plans may also apply. If the Qualified Beneficiary was covered by these benefits prior to termination, the individual may, but is not required to, continue them under COBRA. The benefits, that are to be continued, if any, will be indicated by the Qualified Beneficiary at the time of COBRA enrollment. Life insurance, accidental death and dismemberment benefits, weekly income or long term disability benefits, (if a part of the employer s plan) are not considered for continuance under COBRA. Maximum Time Periods Continuation will be available for a qualified beneficiary up to the maximum time period shown in each item listed below: 1. When coverage terminates due to reduction of hours worked or termination of employment, either voluntary or involuntary, for reasons other than gross misconduct, an employee and his covered dependents may continue coverage under COBRA for up to 18 months. 2. COBRA coverage may be continued up to 36 months for: a. A covered child who ceases to be an eligible dependent (see Notification Responsibility); b. A covered dependent of a deceased employee; c. A former covered spouse whose coverage ceases due to divorce or legal separation (see Notification Responsibility); d. A covered dependent when the employee s coverage ceases due to entitlement for Medicare. 3 There is a special continuation period for retired employees and their dependents when the employer declares bankruptcy under Title 11 of the United States Code and the retired employees and their dependents lose substantial coverage within one year before or after the date the bankruptcy proceeding commenced. a. Coverage will be continued for the retired employee until the date of that person s death. b. The surviving spouse or children of a deceased retired employee may continue coverage for up to a maximum of 36 months following the retired employee s death. NOTE: For this item 3, coverage does not terminate when the person becomes eligible for Medicare. 11

17 The original 18 months may be extended to 36 months for qualified beneficiaries being affected by other events such as, the death of the employee, divorce, legal separation, or Medicare entitlement, which may occur during the original 18 month period. Combined qualifying events will not continue a beneficiary s coverage beyond the date of the original qualifying event for more than 36 months. A disabled individual may extend COBRA from 18 months to 29 months, for an extra fee, provided that: a. The individual is determined as being disabled for Social Security purposes on the date of the qualifying event or within the first 60 days of COBRA coverage; and b. The individual notifies the plan administrator within 60 days of the Social Security Administration s determination of disability and within the original 18 month COBRA period that applies to the person. Notification Responsibility When coverage terminates due to an employee s death, termination, or eligibility for Medicare, the employer has 30 days in which to notify the Plan Administrator of the qualifying event. When coverage terminates due to divorce, legal separation, or change of dependent status, the qualified beneficiary has 60 days from the qualifying event or from the date coverage terminates in which to notify the employer and/or the Plan Administrator that the qualifying event has occurred. Trade Act of 2002 The Trade Act of 2002 created a tax credit for certain individuals who become eligible for trade adjustment assistance. Under the new tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. If you have questions about these new tax provision, you may call the Health Care Tax Credit Customer Contact Center toll free at Termination of COBRA Coverage Continued coverage may cease before the end of the maximum period on the earliest of: 1. The date that the employer ceases to provide a group health and dental plan to any employee; 2. The date that the qualified beneficiary first becomes, after the date of election: a. Covered under any other group health and dental plan as an employee or otherwise. However, a qualified beneficiary who becomes covered under a group health and dental plan which has a pre-existing conditions limit must be allowed to continue COBRA coverage for the length of a pre-existing condition or to the COBRA maximum time period, if less. COBRA coverage may be terminated if the qualified beneficiary becomes covered under a group health plan with a pre-existing condition limit, if the pre-existing conditions limit does not apply to or is satisfied by the qualified beneficiary by reason of the group health plan portability, access and renewal requirements of the Health Insurance Portability and Accountability Act, ERISA, or the Public Health Services Act. b. Entitled to benefits under Medicare, except as stated in item 3 of Maximum Time Periods. 3. The end of the month in which premiums were paid if the cost of continued coverage is not paid within the 30 day grace period of the due date; 4. For an individual who has extended COBRA coverage of 29 months due to disability, COBRA coverage will end in the month that begins more than 30 days after a final determination has been made by the Social Security Administration that the individual is no longer disabled. Complete instructions on how to elect continuation will be provided by the plan administrator within 14 days of receiving notice of the qualifying event. This and all other information will be sent to your last known address. Covered persons then have 60 days in which to elect continuation. The 60-day period is measured from the later of the date coverage terminates or the date notice of the right to continue is sent. If continuation is not elected in that 60-day period, then the right to elect continuation ceases. If you or your dependents have any questions regarding COBRA, or if you have changed marital status, or you or your spouse have changed addresses, please contact Piedmont Community Services Human Resources. 12

18 OCR HIPAA Privacy December 3, 2002 Revised April 3, 2003 NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION [45 CFR ] Background The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. Health plans and covered health care providers are required to develop and distribute a notice that provides a clear explanation of these rights and practices. The notice is intended to focus individuals on privacy issues and concerns, and to prompt them to have discussions with their health plans and health care providers and exercise their rights. How the Rule Works General Rule. The Privacy Rule provides that an individual has a right to adequate notice of how a covered entity may use and disclose protected health information about the individual, as well as his or her rights and the covered entity s obligations with respect to that information. Most covered entities must develop and provide individuals with this notice of their privacy practices. The Privacy Rule does not require the following covered entities to develop a notice: Health care clearinghouses, if the only protected health information they create or receive is as a business associate of another covered entity. See 45 CFR (b)(1). A correctional institution that is a covered entity (e.g., that has a covered health care provider component). A group health plan that provides benefits only through one or more contracts of insurance with health insurance issuers or HMOs, and that does not create or receive protected health information other than summary health information or enrollment or disenrollment information. See 45 CFR (a). Content of the Notice. Covered entities are required to provide a notice in plain language that describes: 13 1

19 OCR HIPAA Privacy December 3, 2002 Revised April 3, 2003 How the covered entity may use and disclose protected health information about an individual. The individual s rights with respect to the information and how the individual may exercise these rights, including how the individual may complain to the covered entity. The covered entity s legal duties with respect to the information, including a statement that the covered entity is required by law to maintain the privacy of protected health information. Whom individuals can contact for further information about the covered entity s privacy policies. The notice must include an effective date. See 45 CFR (b) for the specific requirements for developing the content of the notice. A covered entity is required to promptly revise and distribute its notice whenever it makes material changes to any of its privacy practices. See 45 CFR (b)(3), (c)(1)(i)(C) for health plans, and (c)(2)(iv) for covered health care providers with direct treatment relationships with individuals. Providing the Notice. A covered entity must make its notice available to any person who asks for it. A covered entity must prominently post and make available its notice on any web site it maintains that provides information about its customer services or benefits. Health Plans must also: < Provide the notice to individuals then covered by the plan no later than April 14, 2003 (April 14, 2004, for small health plans) and to new enrollees at the time of enrollment. < Provide a revised notice to individuals then covered by the plan within 60 days of a material revision. < Notify individuals then covered by the plan of the availability of and how to obtain the notice at least once every three years. Covered Direct Treatment Providers must also: 2 14

20 OCR HIPAA Privacy December 3, 2002 Revised April 3, 2003 < < < < Provide the notice to the individual no later than the date of first service delivery (after the April 14, 2003 compliance date of the Privacy Rule) and, except in an emergency treatment situation, make a good faith effort to obtain the individual s written acknowledgment of receipt of the notice. If an acknowledgment cannot be obtained, the provider must document his or her efforts to obtain the acknowledgment and the reason why it was not obtained. When first service delivery to an individual is provided over the Internet, through , or otherwise electronically, the provider must send an electronic notice automatically and contemporaneously in response to the individual s first request for service. The provider must make a good faith effort to obtain a return receipt or other transmission from the individual in response to receiving the notice. In an emergency treatment situation, provide the notice as soon as it is reasonably practicable to do so after the emergency situation has ended. In these situations, providers are not required to make a good faith effort to obtain a written acknowledgment from individuals. Make the latest notice (i.e., the one that reflects any changes in privacy policies) available at the provider s office or facility for individuals to request to take with them, and post it in a clear and prominent location at the facility. A covered entity may the notice to an individual if the individual agrees to receive an electronic notice. See 45 CFR (c) for the specific requirements for providing the notice. Organizational Options. Any covered entity, including a hybrid entity or an affiliated covered entity, may choose to develop more than one notice, such as when an entity performs different types of covered functions (i.e., the functions that make it a health plan, a health care provider, or a health care clearinghouse) and there are variations in its privacy practices among these covered functions. Covered entities are encouraged to provide individuals with the most specific notice possible. Covered entities that participate in an organized health care arrangement may choose to produce a single, joint notice if certain requirements are met. For example, the joint notice must describe the covered entities and the service delivery sites to which it applies. If any one of the participating covered entities provides the joint notice to an individual, the notice distribution requirement with 15 3

21 OCR HIPAA Privacy December 3, 2002 Revised April 3, 2003 respect to that individual is met for all of the covered entities. See 45 CFR (d). Frequently Asked Questions To see Privacy Rule FAQs, click the desired link below: FAQs on Notice of Privacy Practices FAQs on ALL Privacy Rule Topics (You can also go to then select "Privacy of Health Information/HIPAA" from the Category drop down list and click the Search button.) 16

22 Women s Health and Cancer Rights Act Notice Reconstructive Surgery Following Mastectomy To: Employees Who Are Eligible to Participate in the Group Health Plan Re: Notice of Rights to Reconstructive Surgery following Mastectomy On January 1, 1999, a new federal law, the Women s Health and Cancer Rights Act of 1998 became effective for our group health plan. This law requires group health plans that provide coverage for mastectomies, as ours does, to also provide coverage for reconstructive surgery and prostheses following mastectomies. As required under the law, we are sending this notice to inform you about these available benefits. The law mandates that a participant or eligible beneficiary who is receiving benefits on or after the law s effective date for a covered mastectomy, will also receive coverage for: Reconstruction of the breast on which the mastectomy has been performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications of all states of mastectomy, including lymphedemas. This coverage will be provided in consultation with the patient and the patient s attending physician and will be subject to the same amount deductible, coinsurance and/or co-payment provisions otherwise applicable under the plan. If you have any questions about coverage for mastectomies and post-operative reconstructive surgery, please contact your Human Resources department. 17

23 NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to later 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 towards your or your dependents other coverage). However, you must request enrollment within 30 days after your or your dependents other coverage ends (or after the employer that sponsors that coverage stops contributing toward the coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact: Human Resources Piedmont Community Services 24 Clay Street Martinsville, VA (276)

24 This plan imposes a preexisting 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 a six-month period. 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 preexisting condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 30 days after birth, adoption, or placement for adoption. This exclusion may last up to 12 months (18 months if you are a late enrollee) from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days of your prior creditable coverage. Most prior health coverage is creditable coverage and can be used to reduce the preexisting condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12-month (or 18-month) exclusion period by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior health coverage, we will help you obtain one from your prior plan or issuer. There are also other ways that you can show you have creditable coverage. Please contact us if you need help demonstrating creditable coverage. All questions about the preexisting condition exclusion and creditable coverage should be directed to Piedmont Community Services, Human Resources at 24 Clay Street Martinsville, VA Telephone: (276)