Benefit Guide - Lubbock County
Benefit Guide - Lubbock County
This guide is designed to help you understand your benefits. Review this material carefully before making your enrollment decisions. Keep this guide to refer to periodically throughout the year. An electronic copy of this guide, the complete Plan Document for each medical plan, and the ACA Summary of Benefit and Coverage (SBC) is located on the Lubbock County Intranet at : http://countynet. Every full-time employee must enroll. Coverage and/or participation in County benefits is not automatic. It is important to familiarize yourself with the various options and enroll in those that best meet your needs.
If you have any questions or need additional information, the Human Resources Department is here to assist you. Do not hesitate to contact us. Our Mission Opportunity Training Achievement Fostered by Innovation Caring Respect Name Position Phone Number Email Melanie Hall Benefits Manager 806-775-1693 email@example.com Greg George Human Resources Director 806-775-1690 firstname.lastname@example.org Venessa Carter Human Resources Manager 806-775-1691 email@example.com Zachery Gutierrez Administrative Assistant 806-775-1695 firstname.lastname@example.org Welcome Page 1 E E mployee Benefits Guide I Page 01
Medical Insurance Plans TeamChoice EPO To locate participating providers: www.team-choice.com Group Name: Lubbock County Customer Service: 806-795-5959 Aetna PPO To locate participating providers: www.aetna.com/docfind/home.do Plan name: Aetna Choice POS II (Open Access) Customer Service: 1-888-340-6139 User Name Password Pharmacy Benefit Management (PBM) MedImpact www.medimpact.com Customer Service: 1-800-788-2949 User Name Password Dental Insurance Plan Aetna To locate participating providers: www.aetna.com/docfind/home.do Plan name: Dental PPO/PDN Customer Service: 1-877-238-6200 User Name _ _ Password Vision Insurance Plan Superior Vision www.superiorvision.com Customer Service: 1-800-507-3800 Employee Assistance Program (EAP) Interface EAP Customer Service: 1-800-324-4327 or 1-800-324-2490 (Se Habla Espanol) www.4eap.com Login: Lubbock County Password: 842 HSA FSA COBRA WageWorks Customer Service: 1-866-279-8385 Mybenefits.wageworks.com User Name Password TCDRS Retirement www.tcdrs.org Customer Service: 1-800-823-7782 User Name Password Life Insurance VOYA Customer Service: 1-800-537-5024 Security Benefits Luke Ford 806-831-6262 Important Contact Information E E mployee Benefits Guide I Page 02
- Who is Eligible? Employees: You are eligible to receive benefits as a full-time employee if you work at least 30 hours per 7 day work period. Dependents: Eligible dependents are: i
- Your legal spouse i
- Your natural child under 26 years of age i
- Your legally adopted child under 26 years of age i
- Your stepchild under 26 years of age i
- A child for whom you have legal guardianship under 26 years of age Who are My Eligible Dependents? Required Documentation needed to qualify your dependent(s) for coverage. Must be provided within 14 days of enrollment.
- Legal or Common Law Marriage Documents State issued Marriage Certificate or Affidavit of Common Law Marriage filed with the County i
- Biological Child Documents State issued Birth Certificate i
- Stepchild Documents State issued Birth Certificate with state issued Marriage Certificate or affidavit of Common Law Marriage filed with the County i
- Adopted Child Documents Adoption Certificate or Adoption Placement Agreement i
- Disabled Dependent Documents Medical Certification as disabled and incapable of self-sustaining employment and all other appropriate dependent documentation as listed above i
- Grandchild Documents Court papers demonstrating legal guardianship and federal tax return within the last 2 years i
- Legal Guardianship Documents State issued Birth Certificate and court order establishing guardianship Eligibility and Enrollment E E mployee Benefits Guide I Page 03
- Most benefits are paid for on a pre-tax basis; therefore, Federal law limits your ability to make changes during the year. This means you may only change your elections during open enrollment unless you experience a “Qualifying Event.” Benefit elections made during open enrollment are effective at the beginning of the plan year. Make Mid-year Changes The benefit elections you make will remain in effect until the end of the plan year, unless you are affected by one of these life changing events: x Getting married or divorced, x A change in job status (for you or an enrolled dependents), or x Having a baby or adopting a child If you experience any of these qualifying events, you must provide the required supporting documentation and make changes within 30 days of the event.
- Login to www.benefitsolver.com.
- Click on the ‘Change My Benefits’ button to make election changes or to update your basic information.
- Select the life event button then the event you wish to file.
- Mid Year Changes Required Documentation for Qualifying Event Adding yourself and/or dependents to coverage: i
- Marriage - State issued Marriage Certificate or Affidavit of Common Law Marriage filed with the County i
- Birth - State issued Birth Certificate i
- Loss of Other Coverage – Letter indicating the loss of coverage which includes the name of the insured, specific coverage(s) that were lost, and date that coverage(s) were lost Removing yourself and/or dependents from coverage: i
- Divorce – State issued Divorce Decree showing date of divorce i
- Gain of Other Coverage – Letter indicating the gain of coverage which includes the name of the insured, specific coverage(s) that were lost, and date that coverage(s) were lost i
- Death of Dependent – State issued death certificate E E mployee Benefits Guide I Page 06
TeamChoice EPO Your Bi-Weekly Cost Employee Only $10.00 Employee Child(ren) $90.00 Employee Spouse $130.00 Employee Family $170.00 Aetna PPO Your Bi-Weekly Cost Employee Only $75.00 Employee Child(ren) $125.00 Employee Spouse $185.00 Employee Family $240.00 DENTAL Aetna Dental Your Bi-Weekly Cost Employee Only $0 Employee Child(ren) $10.00 Employee Spouse $15.00 Employee Family $20.00 VISION Vision Plan Your Bi-Weekly Cost Employee only $3.42 Employee + 1 $5.83 Employee + Family $8.58 MEDICAL Bi-Weekly Employee Contributions E E mployee Benefits Guide I Page 07
PLAN TEAMCHOICE EPO AETNA PPO BENEFITS IN NETWORK ONLY IN NETWORK NON NETWORK Deductible $1,600 $2,500 $5,000 Co-Insurance 20% 20% 40% Max Out of Pocket $4,000 $5,000 UNLIMITED Family Deductible $3,200 $5,000 $10,000 Family Max Out of Pocket $8,000* $10,000* UNLIMITED Routine Annual Exam $0 – 100% every 12 months $0 – 100% every 12 months DEDUCTIBLE THEN 40% Physician Visit DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 40% Specialist Visit DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 40% Emergency Room DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 40% Urgent Care DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 40% Prescription Drugs DEDUCTIBLE THEN 20% of allowable DEDUCTIBLE THEN 20% of allowable DEDUCTIBLE THEN 40% Complex Imaging DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 40% Outpatient Services DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 40% Inpatient / Hospitalization DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 20% DEDUCTIBLE THEN 40% Lifetime Maximum UNLIMITED UNLIMITED UNLIMITED Network Team Choice Aetna Non Network *No single individual within the family will be subject to more than the individual out-of-pocket maximum amount.
Benefits presented are only a summary. Please refer to the Plan Document and ACA summaries for the complete details at http://countynet/Intranet/Publish/Default.html.
Summary Medical Plans E E mployee Benefits Guide I Page 08
- Register at www.aetna.com to: i
- Print a medical or dental ID card or download the app to view on your phone and show to a provider. i
- View claims, deductibles and maximum out-of-pocket amounts. i
- Payment Estimator – compare cost estimates for health care services. Visit www.team-choice.com to locate in-network physicians and/or facilities. Enter “Lubbock County” as your employer, your city and agree to terms then click search. Aetna TeamChoice If your insurance card has the “Advantage Team Choice” logo on it you are a TeamChoice member.
You should always refer to the TeamChoice website to find doctors, clinics and labs that are in the TeamChoice network. (The Aetna website and Aetna customer service number is not your best resource for Team Choice InformaƟon) Visit the TeamChoice website at www.team-choice.com OR Call Team Choice at 806-795-5959 for assistance with choosing providers or with claims quesƟons Provider Search Employee Benefits Guide I Page 09
E E mployee Benefits Guide I Page 10
- MedImpact Register at www.medimpact.com i
- Drug Price Check Compare drug prices & view most commonly dispensed drugs, which may show a lower cost option than the drug you were prescribed. i
- Claims Review View your current prescription drug claims. Pharmacy Benefit Manager E E mployee Benefits Guide I Page 11
Maintenance Medication Mail Delivery We provide access to home delivery for your regular maintenance medications, those you take routinely for conditions such as high blood pressure, high cholesterol, diabetes, etc. Get up to a 90-day supply with one simple payment. To get started with Medimpact Direct, you can sign up by phone, by mail, or you can have your prescriber submit your prescription to us electronically. E E mployee Benefits Guide I Page 12 Pharmacy Benefit Manager
TelaDoc E E mployee Benefits Guide I Page 13
Aetna Dental Benefits Preventive Services 100% Oral Exams, Routine Cleanings (2 per calendar year) X-Ray – complete mouth (once every 3 calendar years) Bitewings – (1 set per calendar year) Fluoride Treatment (1 every 12 months under age 16) Sealants per tooth—(1 application every 3 calendar year for permanent molar under age 16) Basic Services 80% Basic Restorations Endodontics (root canal therapy) Periodontal (gum treatment) Major Services 50% Inlays, Onlays and Crowns Dentures Bridges Simple and Complex Oral Surgery Individual/Family* $25/$100 Calendar Year Maximum Benefit: $1,500 Orthodontia Adult & Child: Individual Lifetime Maximum Benefit $1,000 You can choose to seek treatment from any dentist.
If your dentist does not file insurance claims, you will pay up front and then complete a reimbursement form and submit it to Aetna. If you select a dentist in the Aetna network, you will receive guaranteed savings. To find dentist in the Aetna network go to www.aetna.com *The deductible applies to basic & major services only. Dental Plan Employee Benefits Guide I Page 14
In-Network Out-of-Network Exam $10 Co-pay Up to $40 retail Frames $150 retail allowance Up to $70 retail Lenses (standard) per pair $10 Co-pay Single Vision Covered in Full Up to $40 retail Bifocal Covered in Full Up to $60 retail Trifocal Covered in Full Up to $80 retail Progressive See description 1 Up to $80 retail Lenticular Covered in Full Up to $80 retail Contact Lenses 2 $150 retail allowance Up to $105 retail Medically Necessary Contact Lenses Covered in Full Up to $210 retail Laser Vision Correction $250 retail allowance 3 Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1.
Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 2. Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit 3. Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations Vision Plan E E mployee Benefits Guide I Page 16
E E mployee Benefits Guide I Page 17 Health Savings Account 2019 Contribution Limits Individual $3,500 Family $7,000 HSA catch-up 55+ $1,000
S Supplemental Life Insurance Lubbock County provides every benefit eligible employee with a $40,000 basic life policy and $40,000 AD&D policy. Voluntary Term Life and AD&D coverage options are: Employee: One to five times your annual salary rounded. Not to exceed $500,000. NOTE: Coverage will require employee to complete an Evidence of Insurability if purchasing for the first time or increasing coverage. Coverage is not guaranteed.
Spouse: Half employee election. NOTE: Coverage will require the spouse to complete an Evidence of Insurability if purchasing for the first time or increasing coverage. Coverage is not guaranteed.
Children: Benefit election maximum is $10,000 for children 6 months to 19 years old and full-time students less than 23 years old. Benefit election maximum is $1,000 for children birth to 6 months. All life insurance premiums will be deducted from your pay post-tax. Term Life Coverage Rates Age Band Life Bi-weekly Rate/$1,000
- E Employee Assistance Program The Employee Assistance Program (EAP) provides cost-free professional consultation, referral services for employees that are experiencing work and personal related issues. Immediate family members are also eligible for EAP services. This benefit is confidential. Issues commonly addressed through your EAP benefit include: i
- Stress management i
- Depression/Anxiety i
- General Wellness i
- Family/Parenting i
- Emotional i
- Alcohol/Drug Abuse i
- Legal referrals i
- Financial referrals Employees and their immediate family members will have access to 5 free face-to-face counseling sessions per problem, per family, per plan year. Lubbock County has teamed up with Wellness Today to keep our employees healthy and fit. If you are looking to reshape your health contact: Michael Fernuik 806-771-8010 Or Michael.email@example.com Wellness Employee Benefits Guide I Page 19 EAP/ Wellness
W Women’s Health and Cancer Rights Act The Women’s Health and Cancer Rights Act (WHCRA) requires that mastectomy patients be provided additional benefits for breast reconstruction, surgery and reconstruction of the other breast to produce symmetry. Coverage should also be provided for prostheses and treatment of physical complications for all stages of a mastectomy, including lymphedema (swelling associated with the removal of lymph nodes). Newborn’s and Mother’s Health Protection Act (NMHPA) The Newborn’s and Mother’s Health Protection Act (NMHPA) restricts limiting the length of a hospital stay in connection with childbirth for a mother or newborn child to less than 48 hours (or 96 hours for a cesarean delivery).
The law does not prohibit earlier discharge if the mother and her attending physician are in agreement that an earlier discharge is appropriate. In addition, authorization of the hospital stay cannot be required for stays of 48 hours or less (or 96 hours) nor are early discharge incentives allowed. Hospital stays begin at delivery or upon hospital admission (whichever is later). Mental Health Parity Act (1996) (MHPA) and Mental Health Parity and Addiction Equity Act (2008) (MHPAEA) The Lubbock County medical plan complies with the Mental Health Parity Act of 1996 (“MHPA”). Pursuant to such compliance, the annual and lifetime limits on Mental Health Benefits, if any, will not be less than the annual and lifetime plan limits on other types of medical and surgical services (if any limits apply).
The plan does utilize cost containment methods, applicable for Mental Health Benefits, including cost-sharing, limits on the number of visits or days of coverage, and other terms and conditions that relate to the amount, duration and scope of Mental Health Benefits. Medicaid & the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace.
For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.
This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
Important Notices Employee Benefits Guide I Page 20
N Notice Of Opportunity To Enroll In Connection With Extension Of Dependent Coverage To Age 26 Individuals whose coverage ended, or who were denied coverage (or were not eligible for coverage), because the availability of dependent coverage of children ended before attainment of age 26 are eligible to enroll in the Lubbock County plan. Individuals may request enrollment for such children for 30 days from the date of notice. Enrollment will be effective retroactively to 10/1/18. If you would like more information, contact your Plan Administrator.
Notice Lifetime Limit No Longer Applies And Enrollment Opportunity The lifetime limit on the dollar value of benefits under Lubbock County plan no longer applies. Individuals whose coverage ended by reason of reaching a lifetime limit under the plan are eligible to enroll in the plan. Individuals have 30 days from the date of this notice to request enrollment. For more information contact Lubbock County Human Resources. Patient Protection Disclosure You do not need prior authorization from the County or from any other person (including a primary care provider) in order to obtain access to obstetrical or medical care from a health care professional in our network who specializes in obstetrics or gynecology.
The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals contact Human Resources. Your Prescription Drug Coverage And Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Lubbock, county and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan.
If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage.
All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Lubbock County has determined that the prescription drug coverage MedImpact is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage with Lubbock County will not be affected. You and/or your dependents can keep this coverage if you elect Part D and this plan will coordinate with Part D coverage. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will be able to get this coverage back. Important Notices Cont.
Employee Benefits Guide I Page 21
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Lubbock County and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage.
For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage... Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Lubbock County changes.
You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage... More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).
C Coverage After Termination (Cobra) Continuation of Health Coverage If you or your dependents have coverage at the time of a qualifying event, you may be eligible to elect continuation of coverage under one or more of the following: Medical Plan Dental Plan Vision Plan You have a legal right under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) to purchase a temporary extension of your coverage at group rates. However, you must pay the full cost of the coverage, plus a 2% administrative fee.
What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After A qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
Important Notices Cont.
Employee Benefits Guide I Page 22
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your hours of employment are reduced, or your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a “dependent child.” C COBRA and Retirement Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event.
If a proceeding in bankruptcy is filed with respect to Lubbock County and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.
W When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: The end of employment or reduction of hours of employment; death of the employee or the employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs.
How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouse, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work.
Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
Important Notices Cont. Employee Benefits Guide I Page 23
There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child.
This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. A Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage.
You can learn more about many of these options at www.healthcare.gov.
If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.
Keep your Plan informed of address changes To protect your family rights, let the Plan Administrator know about any changes in the addresses of family members. Your should also keep a copy, for your records, of any notices you send to the Plan Administrator. Lubbock County Notice of Privacy Practices Effective Date: September 25, 2015 THIS NOTICE DESCRIBES HOW PROTECTED MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. You are receiving this Privacy Notice because you are eligible to participate in a Lubbock County’s sponsored group health plans.
The Health Plans are committed to protecting the confidentiality of any health information collected about an individual. This Notice describes how the Health Plan may use and disclose, “protected health information” (PHI). In order for information to be considered “PHI”, it must meet three conditions: Information is created or received by a health care provider, health plan, employer, or health care clearinghouse; Information relates past, present, or future physical or mental health condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and the information either identifies the individual or provides a reasonable basis for believing that it can be used to identify the individual.
The Health Plan is required by the Health Insurance Portability and Accountability Act (HIPAA) to provide this Notice to an individual. Additionally, the Health Plan is required by law to: Maintain the privacy of an individual’s “protected health information” (PHI), and Provide you with the Privacy Notice of its legal duties and privacy practices with respect to an individual’s PHI, and Follow the terms of its Privacy Notice that is currently in effect. To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
Important Notices Cont.
Employee Benefits Guide I Page 24
Employees of the plan sponsor who administer and manage this Health Plan may use PHI only for appropriate plan purposes (such as for payment or health care operations), but not for purposes of other benefits not provided by this plan, and not for employment-related purposes of the plan sponsor. These individuals must comply with the same requirements that apply to the Health Plan to protect the confidentiality of PHI. Uses and Disclosures of Protected Health Information (PHI) The following categories describe the ways that the Health Plan may use and disclose protected health information.
For each category of uses and disclosures, examples will be provided. Not every use or disclosure in a category will be listed. However, all the ways the Health Plan is permitted to use and disclose information will fall within one of these categories. Treatment Purposes The Health Plan may disclose PHI to a health care provider for the health care provider’s treatment purposes. For example, if an individual’s Primary Care Physician (PCP) or treating medical provider refers the individual to a specialist for treatment, the Health Plan can disclose the individual’s PHI to the specialist to whom they have been referred so (s)he can become familiar with the individual’s medical condition, prior diagnoses and treatment, and prognosis.
Payment Purposes The Health Plan may use or disclose health information for payment purposes; such as, determining eligibility for plan benefits, obtaining premiums, facilitating payment for the treatment and services an individual receives from health care providers, determining plan responsibility for benefit payments, and coordinating benefits with other benefit plans. Examples of payment functions may include reviewing the medical necessity of health care services, determining whether a particular treatment is experimental or investigational, or determining whether a specific treatment is covered under the plan.
Health Care Operations The Health Plan may use PHI for its own health care operations and may disclose PHI to carry out necessary insurance related activities. Some examples of Health Care Operations may include: underwriting, premium rating and other activities related to plan coverage; conducting quality assessment and improvement activities; placing contracts; conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection programs; and business planning, management and general administration of the Health Plan.
To a Business Associate of the Health Plan The Health Plan may disclose PHI to a Business Associate (BA) of the Health Plan, provided a valid Business Associate Agreement is in place between the Business Associate and the Health Plan. A Business Associate is an entity that performs a function on behalf of the Health Plan and that uses PHI in doing so, or provides services to the Health Plan such as legal, actuarial, accounting, consulting or administrative services. Examples of Business Associates include the Health Plan’s Third Party Administrators (TPAs), Actuary, and Broker. To the Health Plan Sponsor The Health Plan may disclose PHI to the Plan Sponsor as long as the sponsor has amended its plan documents, provided a certification to the Health Plan, established certain safeguards and firewalls to limit the classes of employees who will have access to PHI, and to limit the use of PHI to plan purposes and not for non-permissible purposes, as required by the Privacy Rule.
Any disclosures to the plan sponsor must be for purposes of administering the Health Plan. Some examples may include: disclosure for claims appeals to the Plan’s Benefits Committee, for case management purposes, or to perform plan administration functions.
The Health Plan may also disclose enrollment/disenrollment information to the plan sponsor, for enrollment or disenrollment purposes only, and may disclose “Summary Health information” (as defined under the HIPAA medical privacy regulations) to the plan sponsor for the purpose of obtaining premium bids or modifying or terminating the plan. Required by Law or Requested as Part of a Regulatory or Legal Proceeding The Health Plan may use and disclose PHI as required by law or when requested as part of a regulatory or legal proceeding. For example, the Health Plan may disclose medical information when required by a court order in a litigation proceeding, or pursuant to a subpoena, or as necessary to comply with Workers’ Compensation laws.
Public Health Activities or to avert a Serious Threat to Health or Safety The Health Plan may disclose PHI to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. Important Notices Cont. E E mployee Benefits Guide I Page 25
Law Enforcement or Specific Government Functions The Health Plan may disclose PHI to law enforcement personnel for purposes such as identifying or locating a suspect, fugitive, material witness or missing person; complying with a court order or subpoena; and other law enforcement purposes.
Other uses and disclosures will be made only with an individual’s written authorization or that of their legal representative, and the individual may revoke such authorization as provided by section 164.508(b) (5) of the Privacy Rule. Any disclosures that were made when the individual’s Authorization was in effect will not be retracted. An Individual’s Rights Regarding Their PHI An individual has the following rights with respect to their PHI. To submit a request, they must provide a written request to: Human Resources Benefits Manager PO Box 10536 Lubbock, TX 79408 Right to Inspect and Copy PHI An individual has the right to inspect and copy health information about them that may be used to make decisions about plan benefits.
If they request a copy of the information, a reasonable fee to cover expenses associated with their request may be charged.
Right to Request Restrictions) An individual has the right to request restrictions on certain uses and disclosures of their PHI (although the Health Plan is not required to agree to a requested restriction). Right to Receive Confidential Communications of PHI) An individual has the right to receive their PHI through a reasonable alternative means or at an alternative location if they believe the Health Plan’s usual method of communicating PHI may endanger them. Right to Request an Amendment An individual has the right to request the Health Plan to amend their health information that they believe is incorrect or incomplete.
The Health Plan is not required to change the PHI, but is required to provide the individual with a response in either case.
Right to Accounting of Disclosures An individual has the right to receive a list or “accounting of disclosures” of their health information made by the Health Plan, except the disclosures made by the Health Plan for treatment, payment, or health care operations, national security, law enforcement or to corrections personnel, pursuant to the individual’s Authorization, or to the individual. An individual’s request must specify a time period of up to six years and may not include dates prior to April 22, 2004. The Health Plan will provide one accounting of disclosures free of charge once every 12-month period.
Breach Notification An individual has the right to receive notice of a breach of your unsecured medical information. Notification may be delayed if so required by a law enforcement official. If you are deceased and there is a breach of your medical information, the notice will be provided to your next of kin or personal representatives if the plan knows the identity and address of such individual(s).
Important Notices Cont. E E mployee Benefits Guide I Page 26
Right to Paper Copy An individual has a right to receive a paper copy of this Notice of Privacy Practices at any time. The Health Plan’s Responsibilities Regarding an Individual’s PHI The Health Plan is a “covered entity” (CE) and has responsibilities under HIPAA regarding the use and disclosure of PHI. The Health Plan has a legal obligation to maintain the privacy of PHI and to provide individuals with notice of its legal duties and privacy practices with respect to PHI. The Health Plan is required to abide by the terms of the current Notice of Privacy Practices (the “Notice”).
The Health Plan reserves the right to change the terms of this Notice at any time and to make the revised Notice provisions effective for all PHI the Health Plan maintains, even PHI obtained prior to the effective date of the revisions. If the Health Plan revises the Notice, the Health Plan will promptly distribute a revised Notice to all actively enrolled participants whenever a material change has been made. Until Health Plan will promptly distribute a revised Notice to all actively enrolled participants when at such time, the Health Plan is required by law to comply with the current version of this Notice.
T The Health Plan’s Complaint Procedures Complaints about this Privacy Notice or if an individual believes their PHI has been impermissibly used or disclosed, or their privacy rights have been violated in any way, the individual may submit a formal complaint. Complaints should be submitted in writing to: Human Resources Benefits Manager PO Box10536 Lubbock, TX 79408 The complaint will be investigated and a written response will be provided to the individual within 30 days from receipt of the complaint. A written summary of the complaint and any correction action taken will be filed with the Privacy Officer.
The Health Plan will not retaliate against the individual in any way for filing a complaint.
If an individual would like their complaint reviewed by an outside agency, they may contact the Department of Health and Human Services at the following address: Department of Health and Human Services The Hubert H. Humphrey Building 200 Independence Avenue, S.W. Washington, D.C. 20201 New Health Insurance Marketplace Coverage Options and Your Health Coverage PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer.
What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in November 1, 2018 for coverage starting as early as January 1, 2019. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards.
The savings on your premium that you're eligible for depends on your household income.
Important Notices Cont. Employee Benefits Guide I Page 27
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain However, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that could lower your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards.
If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.* Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverageis often excluded from income for Federal and State income tax purposes.
Your payments for coverage through the Marketplace are made on an after-tax basis. E E mployee Benefits Guide I Page 28
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