The Plan will use protected health information (PHI) to the extent of and in accordance with the uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Specifically, the Plan will use and disclose PHI for purposes related to health care treatment, payment for health care and health care operations.
“Payment” includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of Plan benefits that relate to a Member to whom health care is provided. These activities include, but are not limited to, the following:
• Quality assessment;
• Determination of eligibility, coverage and Coinsurance amounts (for example, cost of a benefit or Plan maximums as determined for a Member’s claim);
• Coordination of benefits;
• Adjudication of health benefit claims (including appeals and other payment disputes);
• Subrogation of health benefit claims;
• Establishing employee contributions;
• Risk adjusting amounts due based on enrollee health status and demographic characteristics;
• Billing, collection activities and related health care data processing;
• Claims management and related data processing, including auditing payments, investigating and resolving payment disputes and responding to Member inquiries about payments;
• Obtaining payment under a contract for reinsurance (including stop-loss and excess loss insurance);
• Medical necessity reviews or reviews of appropriateness of care or justification of charges;
• Disclosure to consumer reporting agencies related to the collection of premiums or reimbursement; and
• Reimbursement to the Plan.
“Health Care Operations” include, but are not limited to, the following activities:
• Population-based activities related to improving health or reducing health care costs, protocol development, case management and care coordination, disease management, contacting health care providers and patients with information about treatment alternatives and related functions;
• Rating provider and Plan performance, including accreditation, certification, licensing or credentialing activities;
• Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and creating, securing or placing a contract for reinsurance of risk relating to health care claims (including stop-loss insurance and excess loss insurance);
• Conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse detection and compliance programs;
• Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the Plan, including formulary development and administration, development or improvement of payment methods or coverage policies;
• Business management and general administrative activities of the Plan, including, but not limited to:
• management activities relating to the implementation of and compliance with HIPAA’s administrative simplification requirements; or
• Customer service, including the provision of data analysis for policyholders, plan sponsors or other customers;
• Resolution of internal grievances.
THE PLAN WILL USE AND DISCLOSE PHI TO THE PLAN ADMINISTRATOR AND AS REQUIRED BY LAW AND AS PERMITTED BY AUTHORIZATION OF THE MEMBER
With an authorization, the Plan will disclose PHI to other health benefit plans, health insurance issuers or HMOs for purposes related to the administration of these plans.
The Plan will disclose PHI to the Plan Administrator only upon receipt of a certification from the Plan Administrator that the Plan Documents have been amended to incorporate the following provisions.
WITH RESPECT TO PHI, THE PLAN ADMINISTRATOR AGREES TO CERTAIN CONDITIONS
The Plan Administrator agrees to:
1. Not use or further disclose PHI other than as permitted or required by the Plan document or as required by law;
2. Ensure that any agents, including a subcontractor, to whom the Plan Administrator provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Administrator with respect to such PHI;
3. Not use or disclose PHI for employment-related actions and decisions unless authorized by a Member;
4. Not use or disclose PHI in connection with any other benefit or employee benefit plan of the Plan Administrator unless authorized by the Member;
5. Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which it becomes aware;
6. Make PHI available to a Member in accordance with HIPAA’s access requirements ;
7. Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA;
8. Make available the information required to provide an accounting of disclosures;
9. Make internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Health and Human Services Secretary for the purpose of determining the Plan’s compliance with HIPAA; and
10. If feasible, return or destroy all PHI received from the Plan that the Plan Administrator still maintains in any form, and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made (or if return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction infeasible).
SEPARATION BETWEEN PLAN ADMINISTRATOR AND PLAN
The following employees or classes of employees under the control of the Plan Administrator may be given access to PHI by the Plan or a business associate servicing the Plan:
1. Board of Directors
3. Human Resource/Financial Administration Support
The employees who are included in this description will have access to PHI only to perform the administration functions that the Plan Administrator provides to the Plan. Employees who violate this provision will be subject to sanction. The Plan Administrator will promptly report any violation of this provision to the Plan and will cooperate with the Plan to remedy or mitigate the effect of such violation.
WOMEN’S HEALTH & CANCER ACT
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
1. All stages of reconstruction of the breast on which the mastectomy was performed;
2. Surgery and reconstruction of the other breast to produce a symmetrical appearance;
3. Prostheses; and
4. Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same Deductibles and Coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your claim administrator at 877-405-2926.
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT
The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, Deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. MHPAEA supplements prior provisions under the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits.
GENETIC INFORMATION NONDISCRIMINATION ACT
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits discrimination in group health plan coverage based on genetic information. GINA expands on the provisions in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which protect against discrimination based on genetic information. HIPAA prevents a plan or issuer from imposing a pre-existing condition exclusion based solely on genetic information, and prohibits discrimination in individual eligibility, benefits, or premiums based on any health factor (including genetic information).
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT
The Patient Protection and Affordable Care Act (Affordable Care Act) adds many protections related to employment-based group health plans for you and your family. These include extending dependent coverage up to age 26; prohibiting pre-existing condition exclusions for children under age 19 and for all individuals beginning in 2014; and requiring easy-to-understand summaries of a health plan’s benefits and coverage.
Additional protections that may apply to your plan include the requirement to provide coverage for certain preventive services (such as blood pressure, diabetes and cholesterol tests, regular well-baby and well-child visits, routine vaccinations and many cancer screenings) without cost-sharing, and coverage of emergency services in an emergency department of a hospital outside your plan’s network without prior approval from your health plan.
This Plan, including benefits and policies, does not discriminate on the basis of race, color, national origin, sex, age or disability. It complies with applicable federal civil rights laws. Plan participants needing translation assistance should contact Clearwater toll free at 877-405-2926. If you feel you were discriminated in any way, you can file a grievance with your Human Resources Department at the employer contact information in the general information section, or you can contact Clearwater toll free at 877-405-2926 or in writing to 1301 S. Capital of Texas Hwy., Suite B-202 Austin, TX 78746. Or you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, toll free by phone at 800-368-1019, TDD users, call toll free 800-537-7697, or by mail at U.S. Department of Health and Human Services, 200 Independence Ave. SW., Room 509F, HHH Building, Washington, DC 20201.
ERISA RIGHTS STATEMENT
As a Member in Hoosier Molded Products, Inc. Health Benefits Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan Members shall be entitled to:
Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Securities Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Plan Document and Summary of Benefits. The Plan Administrator may make a reasonable charge for the copies.
The Plan Administrator is required by law to furnish each main subscriber with a copy of this summary annual report. Obtain a statement telling you whether you have a right to receive a pension at normal retirement age and if so, what your benefits would be at normal retirement age if you stop working under the plan now. If you do not have a right to a pension, the statement will tell you how many more years you have to work to get a right to a pension. This statement must be requested in writing and is not required to be given more than once every 12 months. The Plan must provide the statement free of charge.
If your employer is eligible for COBRA coverage, you, your spouse and/or dependents may continue receiving health care benefits if there is a loss of coverage under the plan as a result of a qualifying event.
In addition to creating rights for plan Members, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries’’ of the plan, have a duty to do so prudently and in the interest of you and other Members and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a (pension, welfare) benefit or exercising your rights under ERISA.
If your claim for a (pension, welfare) benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan Documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Lab or, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.