Supplemental Questions

Transcription

1 Health Alliance Supplemental Questions For small group plan enrollees (2 50 employees) Health Alliance shapes solutions for your health care through our superior, top-rated health plan coverage. Whether you need support for a chronic condition, need help understanding your wellness benefits or want access to the best doctors around, Health Alliance has the solution for you. Questions? Visit HealthAlliance.org or call , Monday through Friday, 8 a.m. 5 p.m. Please answer these questions for our records then fill out the attached application. Thank you. 1. Name 2. Please list prior last name(s) if applicable. 3. Employer Name 4. Please list dependents you d like included on the application and their relationship to you. Dependent Name Relationship to you Married Spouse Civil Union Spouse Child Married Spouse Civil Union Spouse Child Married Spouse Civil Union Spouse Child Married Spouse Civil Union Spouse Child 5. Are you and/or your dependent(s) an established patient of the Primary Care Physician (PCP) that you listed on the application? 6. Are you applying for coverage because you ve recently become benefit eligible (gone from being a part-time to full-time employee)? 7. If you are changing your coverage due to any of the following, please select the reason. Continuation Election: Coverage COBRA State Spousal Coverage Dependent Coverage Re-enrolling from layoff Re-enrolling from leave of absence Moved out of service area Left employment: Date of termination / / Too expensive Deceased Switched health plans Cancel coverage Other SUBSCRIBER NUMBER PLAN CODE PLAN TYPE HMO PPO POS POS-C Other APPROVED DISAPPROVED DATE BY mkt-sgappaddendumflr-1113

2

3 Illinois Standard Health Employee Application for Small Employers INSURER USE ONLY Policy/Group. Section. Effective Date New Hire Waiting Period For assistance in completing this application, please contact your employer or insurance agent. For information about your health insurance rights under state and federal law, and other resources, please contact the Illinois Department of Insurance s Office of Consumer Health Insurance toll free at (877) This standard application is intended to simplify your health insurance application process. You will only need to complete this one application, even when your employer has requested quotes from multiple insurance companies. The information you provide in this application will be sent to the following insurance companies: (To be completed by employer) Insurer: Insurer: Insurer: Insurer: Insurer: Insurer: TO BE COMPLETED BY EMPLOYER Employer Name: Phone #: Address: Reason for Enrollment (Mark all that apply) New Enrollment: New Group Open Enrollment New Hire (Date: ) Late Enrollee Special Enrollment: Adoption Court Order Dependent Addition Divorce Domestic Partner Employment Status: Active Loss of Coverage Marriage Newborn Other Date of Event: / / Illinois Continuation Employee Retiree (Retirement Date: / / ) COBRA Dependent Qualifying Event: Start Date / / Projected End Date / / A Employee Information Name (Last) (First) (MI) Job Title: Hire Date: Hrs/Week: Marital Status: Married Single Divorced Widowed Domestic Partner Home Address: Apt #: City: State: Zip: Home (or Cell) Phone: ( ) Business Phone: ( ) Address (optional): B Coverage Requested Medical Employee: Spouse/Domestic Partner: Child(ren): Plan Choice: Plan Choice: Plan Choice: If you are waiving (declining) coverage for yourself or any member of your family, you must complete Section C below.

4 ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name C Waiver of Coverage Please complete this section only if you are waiving (declining) coverage for yourself or one or more of your family members. I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer. I understand and agree: If I am declining coverage for myself, my spouse/domestic partner, or my dependent child(ren) because of other coverage, I may in the future be able to enroll myself, my spouse/domestic partner, or my dependent child(ren) provided that I request enrollment within 31 days after the other coverage ends. If I have a new spouse/domestic partner or child as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my new spouse/domestic partner or child provided that I request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption. If I decide to request coverage in the future, for a reason other than the termination of other coverage or the addition of a new spouse/domestic partner or child, I may be considered a late enrollee, if applicable, or I may have to wait until the plan s next open enrollment period. I also understand that as a late enrollee, coverage for preexisting conditions may be excluded for up to a period of 18 months. This period may be offset by the time I, my spouse/domestic partner, or my dependent child(ren) was covered under a qualified health plan. I certify that I was not pressured, forced, or unfairly induced by my employer, the agent, or the insurer(s) into waiving or declining the group coverage. I DO NOT want, and hereby waive, coverage for (initial next to all that apply): Medical for [ ] Myself [ ] My Spouse/Domestic Partner [ ] My Dependent Child(ren) Dental for [ ] Myself [ ] My Spouse/Domestic Partner [ ] My Dependent Child(ren) Vision for [ ] Myself [ ] My Spouse/Domestic Partner [ ] My Dependent Child(ren) Basic Life for [ ] Myself [ ] My Spouse/Domestic Partner [ ] My Dependent Child(ren) Dependent Life for [ ] Myself [ ] My Spouse/Domestic Partner [ ] My Dependent Child(ren) Voluntary Life for [ ] Myself [ ] My Spouse/Domestic Partner [ ] My Dependent Child(ren) Short-Term Disability for [ ] Myself [ ] My Spouse/Domestic Partner [ ] My Dependent Child(ren) Long-Term Disability for [ ] Myself [ ] My Spouse/Domestic Partner [ ] My Dependent Child(ren) If offered. I am declining group coverage for the following reason(s): (check all that apply) Spouse/Domestic Partner s Employer Plan COBRA/State Continuation Individual Coverage (n-group Plan) Medicare or other Government Program Other (please explain): If you are declining ALL coverage for ALL persons, please skip to the Acknowledgement & Signature section on page 10 of this application. 2

5 ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name D Individuals Requesting Coverage List yourself and all eligible family members to be included under coverage. Please check with your employer or insurance agent about who may qualify as an eligible family member under the policy. Illinois Young Adult Dependent Coverage law allows parents to cover children up to the age of 26, and up to age 30 for military veteran dependents, regardless of whether the child may be considered a dependent for tax or other purposes. For more information, please visit the Illinois Department of Insurance website at te: For purposes of this application, an eligible military veteran is a veteran who served in the active or reserve components of the U.S. Armed Forces, including the National Guard, and who received a release or discharge other than a dishonorable discharge. If additional space is required, please attach a separate sheet and be sure to sign and date that sheet. Employee Name (Last) (First) (MI) Social Security Number: Date of Birth: / / Gender: Male Female HMO only (if/when applicable): Primary Care Physician: Physician ID: Spouse/Domestic Partner Name (Last) (First) (MI) Social Security Number: Date of Birth: / / Gender: Male Female HMO only (if/when applicable): Primary Care Physician: Physician ID: Dependent Name (Last) (First) (MI) Social Security Number: Date of Birth: / / Gender: Male Female Eligible Military Veteran: HMO only (if/when applicable): Primary Care Physician: Physician ID: Dependent Name (Last) (First) (MI) Social Security Number: Date of Birth: / / Gender: Male Female Eligible Military Veteran: HMO only (if/when applicable): Primary Care Physician: Physician ID: Dependent Name (Last) (First) (MI) Social Security Number: Date of Birth: / / Gender: Male Female Eligible Military Veteran: HMO only (if/when applicable): Primary Care Physician: Physician ID: 3

6 ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name Dependent Name (Last) (First) (MI) Social Security Number: Date of Birth: / / Gender: Male Female Eligible Military Veteran: HMO only (if/when applicable): Primary Care Physician: Physician ID: E Current/Prior Coverage Information Please indicate for EACH person listed on this application any health coverage, including Medicare or Medicaid, in effect within 24 months prior to the proposed effective date of this coverage. Each person applying for coverage must be listed below. If no health care coverage was in effect within the past 24 months, please indicate NONE. If coverage is provided for a dependent from a previous marriage or relationship, please attach a copy of the court documentation showing who is responsible for the dependent(s) health care coverage so that the insurer can determine whose coverage is primary. te: If you have had health care coverage within the last 63 days, your Pre-Existing Condition (PEC) waiting period limitation may be partially or completely waived. To determine if this applies to you, you must provide proof of prior coverage, such as a Certificate of Creditable Coverage from your previous insurer. Submission of prior coverage information does not automatically waive any PEC limitation. You will be subject to an automatic PEC Waiting Period of up to 12 months until the insurer receives evidence of prior coverage. If additional space is required, please attach a separate sheet and be sure to sign and date that sheet. Employee Name (Last) (First) (MI) Current/Most Recent Coverage: Group Medical Dental Individual Medical ne Will the individual continue this coverage? Prior Coverage (if any): Group Medical Dental Individual Medical ne Spouse/Domestic Partner Name (Last) (First) (MI) Current/Most Recent Coverage: Group Medical Dental Individual Medical ne Will the individual continue this coverage? Prior Coverage (if any): Group Medical Dental Individual Medical ne Dependent Name (Last) (First) (MI) Current/Most Recent Coverage: Group Medical Dental Individual Medical ne Will the individual continue this coverage? Prior Coverage (if any): Group Medical Dental Individual Medical ne 4

7 ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name Dependent Name (Last) (First) (MI) Current/Most Recent Coverage: Group Medical Dental Individual Medical ne Will the individual continue this coverage? Prior Coverage (if any): Group Medical Dental Individual Medical ne Dependent Name (Last) (First) (MI) Current/Most Recent Coverage: Group Medical Dental Individual Medical ne Will the individual continue this coverage? Prior Coverage (if any): Group Medical Dental Individual Medical ne Dependent Name (Last) (First) (MI) Current/Most Recent Coverage: Group Medical Dental Individual Medical ne Will the individual continue this coverage? Prior Coverage (if any): Group Medical Dental Individual Medical ne Medicare: If you or any family members listed on this application have Medicare coverage, please complete the following information. Enrolling Individual Name (Last) (First) (MI) Medicare Part A Part B Part D Effective Date: / / Reason for Medicare Entitlement: Age Disability ERSD Dual Enrollment Medicare Number (please include alpha prefix): Enrolling Individual Name (Last) (First) (MI) Medicare Part A Part B Part D Effective Date: / / Reason for Medicare Entitlement: Age Disability ERSD Dual Enrollment Medicare Number (please include alpha prefix): 5

8 DOES NOT APPLY ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name F Health Statement Instructions: 1. The information you provide in this application is confidential. You should discuss with your employer if you prefer to submit the completed health statement directly to the insurance company or insurance broker. 2. The health information you provide below will be used by the insurance company to determine the price to charge your group for the coverage applied for and whether a Pre-Existing Condition Waiting Period(s) will apply to your coverage. Coverage for pre-existing conditions cannot be limited or excluded for dependents under the age of Each medical question below applies to all persons requesting coverage. 4. Answer the questions below with either or. If you answer to any question, you must provide additional information in Section G below. 5. Do not leave any question unmarked. 6. Neither your employer nor your insurance agent can waive these requirements or may authorize you to provide anything less than a complete and accurate response to each of the questions. 7. After you submit this application, the insurance company may call you to obtain additional confidential information needed to evaluate and aid the processing of your application. 1 For the following conditions, within the past 5 years, have you or any dependents for whom you are requesting coverage: Been tested for or diagnosed with; Had medical treatment recommended; Received medical treatment, including prescription medications; or Been hospitalized for any illness, injury, or health condition related to any of the categories listed below? A. Cardiovascular disease or heart attack, stroke, high blood pressure, or any other disease or disorder of the heart, arteries, blood, or blood vessels? B. Cancer or cancerous tumor? C. Asthma, emphysema, tuberculosis, or any other disorder of the lungs or respiratory system? D. Diabetes? If yes, check all that apply: n-insulin Dependent Insulin Dependent Insulin Pump E. Hepatitis, or any disorder of the liver, stomach, colon, or intestines? F. Growth disorder or a disorder of the pancreas? G. Chronic kidney stones, or other disorders of the kidney, prostate, or bladder? H. Reproductive organ disorders or infertility? I. Arthritis, or any other disorder of the joints, muscles, back, or bones? J. Mental or emotional disorder? K. Seizures/epilepsy, paralysis, or any other disorder of the brain or nervous system? 6

9 ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name L. HIV positive, AIDS, diseases associated with AIDS, lupus, or other disorder of the immune system? M. Alcohol, drug, or substance use or dependency? N. Organ or bone marrow transplant? DOES NOT APPLY 2 Are you, your spouse/domestic partner, or any dependent for whom you are requesting coverage currently pregnant? Due Date: / / (MM/DD/YYYY) If yes, are multiples (twins, triplets, etc.) expected? Are there any known complications, or is a cesarean section planned? 3 Within the past 12 months, have you or your spouse/domestic partner used any tobacco products? Employee: Spouse/Domestic Partner: 4 Within the past 12 months, has any applicant been prescribed medication (other than for the common cold or flu) that is not indicated elsewhere in this application? 5 Within the past 5 years, has any person applying for coverage been tested for or diagnosed with, had medical treatment recommended, received medical treatment, including prescription medications, or been hospitalized for any illness, injury or health condition not indicated above? G Additional Information DOES NOT APPLY If you answered to any of the questions above, you must complete this section. If additional space is required, please attach a separate sheet and be sure to sign and date that sheet. Question Number: Name of Individual: Condition/Diagnosis: Date Diagnosed (MM/YYYY): Treatment Received: Treatment ongoing? Last Treatment Date: Surgery, additional tests or treatment recommended? Medication Prescribed (if any): Currently taking medication? Question Number: Name of Individual: Condition/Diagnosis: Date Diagnosed (MM/YYYY): Treatment Received: Treatment ongoing? Last Treatment Date: Surgery, additional tests or treatment recommended? Medication Prescribed (if any): Currently taking medication? 7

10 DOES NOT APPLY ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name Question Number: Name of Individual: Condition/Diagnosis: Date Diagnosed (MM/YYYY): Treatment Received: Treatment ongoing? Last Treatment Date: Surgery, additional tests or treatment recommended? Medication Prescribed (if any): Currently taking medication? Question Number: Name of Individual: Condition/Diagnosis: Date Diagnosed (MM/YYYY): Treatment Received: Treatment ongoing? Last Treatment Date: Surgery, additional tests or treatment recommended? Medication Prescribed (if any): Currently taking medication? Question Number: Name of Individual: Condition/Diagnosis: Date Diagnosed (MM/YYYY): Treatment Received: Treatment ongoing? Last Treatment Date: Surgery, additional tests or treatment recommended? Medication Prescribed (if any): Currently taking medication? Question Number: Name of Individual: Condition/Diagnosis: Date Diagnosed (MM/YYYY): Treatment Received: Treatment ongoing? Last Treatment Date: Surgery, additional tests or treatment recommended? Medication Prescribed (if any): Currently taking medication? Question Number: Name of Individual: Condition/Diagnosis: Date Diagnosed (MM/YYYY): Treatment Received: Treatment ongoing? Last Treatment Date: Surgery, additional tests or treatment recommended? Medication Prescribed (if any): Currently taking medication? 8

11 ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name H Additional Coverage Options You should complete this section only if your employer offers any of the additional coverage options below. Employee Dental: PPO HMO Dental HMO Office ID # (if applicable): Vision Basic Life Dependent Life Voluntary Life: Amount (if applicable): $ Short-Term Disability Long-Term Disability Employee Class (employer will provide you with this information if needed): Salary (if requesting life or disability coverage): $ Hourly Weekly Monthly Semi-monthly Annually Spouse/Domestic Partner Dental: PPO HMO Dental HMO Office ID # (if applicable): Vision Basic Life Dependent Life Voluntary Life: Amount (if applicable): $ Short-Term Disability Long-Term Disability Child(ren) Dental: PPO HMO Dental HMO Office ID # (if applicable): Vision Basic Life Dependent Life Voluntary Life: Amount (if applicable): $ Short-Term Disability Long-Term Disability Beneficiary Information (if requesting life insurance) Primary Beneficiary Name (Last, First, MI) Relationship Benefit % Secondary Beneficiary Name (Last, First, MI) Relationship Benefit % 9

12 ILLINOIS STANDARD HEALTH APPLICATION SMALL EMPLOYER Employer Name Employee Name I Acknowledgement & Signature I understand, agree, and represent that: I have read this document or it has been read to me. The answers provided within this entire application for coverage are, to the best of my knowledge and belief, true and complete. Neither my employer nor the agent has the authority to waive a complete answer to any question, determine coverage or insurability, alter any contract, or waive any of the insurance carrier s other rights and requirements. I understand that if I intentionally omit or provide false information on or in relation to this application, then this policy may be cancelled retroactively, in which case any claim I submit may not be paid by the insurer. I understand that if I intentionally omit or provide false information on or in relation to this application that I may face legal liability, including legal action based on fraud. If this application for coverage is accepted, coverage will be effective on the date specified by the insurance carrier on the certificate of coverage/certificate of insurance. I hereby enroll for benefits as indicated in Section B and Section H of this application, for which I am presently eligible or for which I may become eligible under my employer s group contract(s). If any deductions are required for this coverage, I authorize such deductions from my earnings. I reserve the right to revoke this deduction authorization at any time upon written notice. I understand that the information I have provided in this application will be used by the insurance carrier and its affiliates to make decisions regarding eligibility, enrollment, underwriting, and premium risk rating. I understand that the medical information provided also includes my spouse/domestic partner and/or dependents information. I understand that I may be asked for authorization to disclose my medical, claim, or benefit records at a later time. I understand that I should retain a duplicate copy of this application for my own records. A photographic copy of this acknowledgment shall be as valid as the original. I authorize the insurance carrier to electronically transmit the information contained herein. If this application was taken over the phone or on the computer, I acknowledge that I, myself, have not actually signed this application but instead hereby authorize the insurance carrier to print Electronically Acknowledged on the signature line of the application and I agree that such printing shall be treated as a valid signature for all purposes of this form. I acknowledge that the insurance carrier has verified my identity for this purpose in accordance with any applicable law or regulation. By signing below, I acknowledge that I have read and understand this document and I am signing of my own free will. Employee Signature Date For assistance in completing this application, please contact your employer or insurance agent. For information about your health care rights under state and federal law, and other resources, please contact the Illinois Department of Insurance s Office of Consumer Health Insurance toll free at (877)

13 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. Effective date of this notice: April 14, S. Vine St. Urbana, Illinois Protecting the privacy of information about your medical conditions and health is a responsibility we take very seriously. We understand that medical information about you and your health is personal and it is important to you that we keep it confidential. We are committed to the practices and procedures we established to protect the confidential nature of information about your health. This notice describes the way we may use and disclose information about your health to carry out treatment, payment and health care operations and for other purposes as permitted or required by law. It also describes your rights and duties regarding the use and disclosure of medical information. INFORMATION THAT THIS NOTICE APPLIES TO This notice applies to any information in our possession that would allow someone to identify you and learn something about your health. It does not apply to information that could only be used to identify you. We collect such personal information as name, address, telephone number, Social Security number, age, sex and medical diagnosis to coordinate medical care. This information is obtained from member enrollment forms, member surveys and claims. OUR LEGAL RESPONSIBILITIES We are required to maintain the privacy of your medical information. We are required to provide this notice of privacy practices and legal duties regarding medical information to anyone who asks for it. We are required to abide by the terms of this notice until we officially adopt a new notice. We will not sell your protected health information. We will not use or disclose genetic information for underwriting purposes. USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION The following categories describe different ways we may use and disclose protected health information without your authorization. For each category, we give some examples of uses and disclosures. t every use or disclosure in a category is listed. However, all of the ways we are permitted to use and disclose protected health information will fall within one of these categories. Treatment: We do not provide medical treatment or services. We may disclose information about your health to a physician or health care professional involved in making a decision that could affect your care. For example, we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription contradicts prior prescriptions. Payment: We use and disclose information about your health to determine eligibility for benefits and payment of claims for medical treatment or services. For example, we may disclose information to your health care provider to verify coverage for medical treatment or services. Likewise, we may share medical information with a health care provider to assist in billing or filing claims for payment of treatment and services, including third party liability claims and coordination of benefits. We may also send you information about claims we pay and claims we do not pay (called an explanation of benefits ) for you and your covered dependents. Under certain circumstances, you may request to receive this information confidentially. cmp-npp-1213

14 Health Care Operations: We may use and disclose your medical information for activities that are necessary for our HMO and health insurance operations. These uses and disclosures are necessary for our business and to make sure you are receiving quality services. Some examples of how we may use and disclose information about your health include: case management and care coordination; conducting quality assessment and improvement activities such as outcomes evaluation and development of clinical guidelines; underwriting, premium rating and other activities relating to coverage; submitting claims for stop-loss or reinsurance coverage; conducting or arranging for medical review; fraud and abuse detection programs; business planning and development such as cost management; and business management and general administrative activities. We may also disclose information about your health to our business associates to enable them to perform services for us or on our behalf relating to our operations. Some examples of business associates are our lawyers, auditors, accrediting agencies, consultants, pharmacy benefit managers, collection agencies and printing and mail service vendors. Our business associates are required to maintain the same high standards of safeguarding your privacy that we require of our own employees and affiliates. OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES THAT MAY BE MADE WITHOUT CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT We may use or disclose your protected health information in the following situations without your authorization or without allowing you to object or agree to the use or disclosure. Legal Requirements: We may use and disclose your medical information when we are required to do so by law. This includes disclosing your protected health information to a government health oversight agency for activities authorized by law, including audits, investigations, inspections and licensure. For example, we may be required to disclose your medical information, and the information of others, if we are audited by the Illinois Department of Insurance. We will also disclose your medical information when we are required to do so by a court order or other judicial or administrative process. To Report Abuse: We may disclose your medical information when the information relates to abuse, neglect or domestic violence. We will make this report only in accordance with laws that require or allow such reporting or with your permission. Law Enforcement: We may disclose your medical information for law enforcement purposes. This includes providing information to help locate a suspect, fugitive, material witness, missing person or in connection with suspected criminal activity. We may disclose protected health information in response to court orders or in emergency circumstances related to a crime. We may also disclose your medical information to a federal agency investigating our compliance with federal privacy regulations. Family and Friends: Unless you object or law prohibits it, we may disclose your medical information to a member of your family or to someone else involved in your medical care or payment for care. This may include telling a family member about the status of a claim or what benefits you are eligible to receive. To Avert a Serious Threat: We may disclose your medical information if we decide that the disclosure is necessary to prevent serious harm to the public or to an individual. The disclosure will only be made to someone who is able to prevent or reduce the threat. Health Benefits and Services: We may use your medical information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. Workers Compensation: We may disclose medical information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs that provide benefits for work-related injuries and illnesses. Your Employer or Organization Sponsoring your Group Health Plan (Plan Sponsor): We may disclose eligibility, enrollment and disenrollment information about you to the Plan Sponsor. We may also disclose summary health information to the Plan Sponsor for the purpose of obtaining premium bids or modifying, amending or terminating the group health plan.

15 In addition, we may disclose other health information to the Plan Sponsor for plan administration upon certification from the Plan Sponsor that they have agreed to special restrictions on the use and disclosure of this information. Refer to your group health plan documents on additional health information the Plan Sponsor may receive. ORGANIZED HEALTH CARE ARRANGEMENTS We may share information that we have about you within our organization and with Carle and its affiliates; and with Springfield Clinic, Memorial Medical Center and their affiliates for purposes of health care operations under an organized health care arrangement. Sharing information enables us to: Determine our financial risk Resolve quality of care complaints Arrange for medical and clinical peer review Improve our methods of payment or coverage policies Arrange for legal services Perform utilization management services YOUR RIGHTS The following describes your rights regarding the protected health information we maintain about you. If you want to exercise your rights, please contact a member of our Customer Service Department, who will give you the necessary information and forms for you to return to the address listed under Whom to Contact at the end of this notice. Authorization: We may use and disclose your medical information for any purpose that is listed in this notice without your written authorization. We will not use or disclose your medical information for any other reason without your authorization. If you authorize us to use or disclose your medical information, you have the right to revoke the authorization at any time. You may not revoke an authorization for us to use and disclose your medical information to the extent that we have taken action in reliance on the authorization. If the authorization is to permit disclosure of your information to an insurance company, as a condition of obtaining coverage, other laws may allow the insurer to continue to use your information to contest claims or your coverage, even after you have revoked the authorization. We will receive your authorization to use or disclose your information for certain marketing activities. Request Restrictions: You have the right to request that we restrict uses and disclosures of your medical information that we use for treatment, payment and health care operations. You also have the right to request a limit on the information we disclose about your health to someone who is involved in your care or the payment of your care, like a family member. We will consider your request, however, we are not required to agree to a restriction. We cannot agree to restrict disclosures that are required by law. Receive Confidential Communications: If our normal communication channels could endanger you, you have the right to request that we send communications that contain your medical information by alternative means or to an alternative location. We will ask you the reason for your request, and we will accommodate all reasonable requests to the extent the request specifies an alternative location and allows us to continue to pay claims. Inspect and Copy: You have the right to inspect the medical information we maintain about you in our records and to receive a copy of it. This right is limited to information about you that is used to make decisions such as claims, payment and enrollment records. Under state and federal law, this right does not include psychotherapy notes or information about your health compiled in reasonable anticipation of litigation, administrative action or administrative proceedings. To inspect your records or to receive a copy, send your written request to the address listed under Whom to Contact at the end of this notice. We may charge a fee for the cost of copying and mailing the records. We will respond to your request within 30 days. We may deny you access to certain information if it would reasonably endanger the life or physical safety of you or another person. If you are denied access to information about your health, we will explain how you may appeal the decision.

16 Amend: You have the right to request that we amend your medical information for as long as we maintain such information if you believe the information is incorrect or incomplete. This right is limited to information about you that is used to make decisions such as claims, payment and medical case management records. Your written request must include the reason or reasons that support your request. We will respond to your request in writing within 30 days. We may deny your request for an amendment if we determine the record that is the subject of the request was not created by us, is not available for inspection as specified by law or is accurate and complete. Accounting of Disclosures: You have the right to receive an accounting of certain disclosures of your medical information made by us in the six years prior to the date the accounting is requested (or shorter period as requested). This does not include disclosures made to carry out treatment, payment and health care operations; disclosures made to you; disclosures made with your authorization; communications with family and friends; disclosures made for national security or intelligence purposes; disclosures to correctional institutions or law enforcement officials; or disclosures made prior to April 14, We will provide the first list of disclosures you request at no charge. A reasonable, cost-based fee may be imposed for each subsequent request. You must tell us the time period you want the list to cover. If a breach of your information occurs, we will notify you within 60 days. Receive a Paper Copy: You have the right to obtain a paper copy of this notice at any time. Complaints: You have a right to complain about our privacy practices, if you think your privacy has been violated. You may file your complaint with our Customer Service Department. (See Whom to Contact at the end of this notice.) You may also file a complaint directly with the Secretary of the U.S. Department of Health and Human Services. We will not take any retaliation against you if you file a complaint. Maintaining Confidentiality of Member Information: The security of our members personal information is very important to us. Member information is never sold to anyone, for any purpose. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your privacy. All Health Alliance employees are educated on our standards and are required to sign a confidentiality and security agreement annually. Any employee found to be in violation of our privacy practices is subject to disciplinary action. Employees are encouraged to report violations of confidentiality using the Health Alliance compliance hotline. CHANGES TO THIS NOTICE We reserve the right to change our privacy practices, as described in this notice, at any time. We reserve the right to apply these changes to any medical information we already have, as well as to medical information we receive in the future. Before we make any change in the privacy practices described in this notice, we will mail a revised notice to you within 60 days of the effective date. WHOM TO CONTACT You may contact a member of our Customer Service Department by calling the number listed on the back of your Member Identification Card (TTY for the hearing impaired) or in writing at 301 S. Vine Street, Urbana, IL, 61801: For more information about this notice and/or our privacy policies To exercise your rights as described in this notice To request a copy of the current notice Representatives are available from 8 a.m. to 5 p.m. Monday through Friday. This notice is also available on our website at: HealthAlliance.org

17

18 tice 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 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 31 days after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). If you or your dependents become ineligible for Medicaid or a state child health insurance program (CHIP) and coverage is terminated, you and your dependents may enroll in this plan if eligible. You must request enrollment within 60 days after Medicaid or CHIP coverage is terminated. If you or your dependents become eligible for a premium assistance subsidy under Medicaid or CHIP, you and your dependents may enroll in this plan if eligible. You must request enrollment within 60 days after eligibility for the premium assistance subsidy is determined. In addition, if you have a new dependent as a result of marrage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption or placement for adoption. To request special enrollment or obtain more information, contact the Health Alliance Customer Service Department at Dependent Child Coverage Under Illinois law, dependent coverage eligibility extends to age 26 for children, regardless of marital or student status. For dependents who are veterans and an Illinois resident and received a release or discharge other than a dishonorable discharge, dependent coverage eligibility is extended to age 30. If your plan provides coverage for dependent children after age 26 who are full-time students, coverage is continued for a dependent student who takes a medical leave of absence or reduces his/her course load to part-time status due to catastrophic illness or injury. This continuation of coverage ends 12 months after notice of the injury or illness or the date coverage would lapse under the terms and conditions of your plan, whichever comes first. An annual enrollment period is required to allow eligible dependent children to enroll in the plan. For more information, call Customer Service at cmp-ilspendepcvgnotice-0712