COBRA Benefits Guide Inside: 2020-21 Benefits Information Health Plan Comparisons Contact Information - Mesa Public Schools
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2020-2021 COBRA Benefits Guide Inside: 2020-21 Benefits Information Health Plan Comparisons Contact Information
MEDICAL PLAN CHOICES
For 2020-2021 our plan year will be July 1, 2020 through June 30, 2021. Mesa Public Schools will continue
to provide three medical plans through Cigna. Each plan option are high-quality options, with the same
services and network. Make certain you carefully review and compare each plan to determine which best
meets the needs for you and your family. If you have questions regarding our medical plans, please call
Cigna’s Pre-Enrollment Hotline at 1-888-806-5042.
Highlights of the Medical Plan Options Offered by Mesa Public Schools
OAP HDHP 1500 HDHP 2500
(Cigna OAP Copay Plan) (Cigna Choice Plan) (Cigna Choice Plan)
In-Network only** In-Network Out of Network In-Network Out of Network
You Pay: You Pay: You Pay: You Pay: You Pay:
Annual Deductible
For employee only $700 $1,500 $3,000 $2,500 $5,000
For employee + 1 $1,400
For employee + family $2,100 $3,000 $6,000 $5,000 $10,000
Out-of-Pocket-Limit
For one person $4,250 $4,000 $8,000 $3,500 $7,000
For your family of 2 or more $8,500 $8,000 $16,000 $7,000 $14,000
Tier 1: Cigna Care Designated
(CCD)****
PCP: $20 copay/visit
Doctor’s Office Visits Specialist: $30 copay/visit 20%* 40%* 10%* 50%*
Tier 2: PCP: $30 copay/visit
Specialist: $50 copay/visit
Urgent Care Facility Visit $60 copay/visit 20%* 40%* 10%* 50%*
X-rays, lab work $0* 20%* 40%* 10%* 50%*
Outpatient facility
Office visit copay applies
Doctor’s Office 20%* 40%* 10%* 50%*
except for preventive care
Well Child Care $0 0% Not covered 0% Not covered
Well Women Care $0 0% Not covered 0% Not covered
Adult Preventive Care $0 0% Not covered 0% Not covered
Immunizations $0 0% Not covered 0% Not covered
$300 copay per admission,
Hospital Care (Inpatient) 20%* 40%* 10%* 50%*
then you pay 20%*
Emergency room (ER) visit $250 copay per visit* 20%* 20%* 10%* 10%*
Ambulance service $0* 20%* 20%* 10%* 10%*
Outpatient Surgery
Professional Fees $0* 20%* 40%* 10%* 50%*
Facility Fees $250 copay* 20%* 40%* 10%* 50%*
Outpatient Physical, Speech and
Occupational Therapies up to a $50 copay per visit* 20%* 40%* 10%* 50%*
combined 50 days per calendar
year
Mental Health &
Substance Abuse Treatment
$300 copay per admission,
Inpatient 20%* 40%* 10%* 50%*
then you pay 20%*
Outpatient $30 copay/visit 20%* 40%* 10%* 50%*
EAP Preferred EAP Preferred EAP Preferred
EAP Visits Not covered Not covered
8 visits - $0 8 visits - $0 8 visits - $0
MPS 2020-2021 Enrollment Guide 1OAP HDHP 1500 HDHP 2500
(Cigna OAP Copay Plan) (Cigna Choice Plan) (Cigna Choice Plan)
In-Network only** In-Network Out of Network In-Network Out of Network
You Pay: You Pay: You Pay: You Pay: You Pay:
Prescription Drugs
(Outpatient)
Combined Combined Combined Combined
medical and medical and medical and medical and
pharmacy pharmacy pharmacy pharmacy
Annual outpatient $100 annual deductible deductible. deductible. deductible. deductible.
prescription drug (Rx) per person. Deductible Deductible Deductible Deductible
deductible per person must be must be must be must be
satisfied before satisfied before satisfied before satisfied before
coinsurance coinsurance coinsurance coinsurance
applies*** applies*** applies*** applies***
Generic - $10 copay
Preferred Brand - $40 copay
30-day supply (retail)* 20%* 40%* 10%* 50%*
Non-preferred Brand - 40% to
a maximum of $120
Generic - $14 copay
Preferred Brand - $70 copay
90-day supply (mail order)* 20%* Not covered 10%* Not covered
Non-preferred Brand - 40% to
a maximum of $200
* After Deductible.
** There is no out-of-network coverage for the OAP Copay Plan, except for emergency services.
*** Preventive medications on Cigna’s Core list are covered at 100% and not subject to deductible.
**** Cigna Care Designated (CCD) providers see page 3 for instructions on how to find a CCD provider
The chart above does not provide a complete list of covered services. Please see your Plan Document for a complete list. If there is any discrepancy
between this chart and the Plan Document, the Plan Document will govern. Copies of the Plan documents are on file in the Employee Benefits
Department and available online at www.mpsaz.org/benefits.
TELEHEALTH
Cigna Telehealth is an alternative option that lets you connect with a board-certified doctor either via video chat or phone,
without leaving your home or work. Cigna provides access to two telehealth services—Amwell or MDLIVE doctors—as part of
your medical plan. These services cost less than going to an urgent care clinic and significantly less than an emergency room.
Telehealth Rates
PLAN OAP HDHP 1500/HDHP 2500
Amwell $15/copay $55
MDLive $15/copay $55
DID YOU KNOW
Healthy Pregnancies, Healthy Babies program is designed to help you and your baby stay healthy during your pregnancy and in
the days and weeks after your baby’s birth. You will be eligible to receive a $250 gift card if you enroll in the first trimester and
$125 if you enroll in the second trimester.
MYCIGNA APP
You’re busier than ever. While we can’t wave a magic wand, and make all the frustrating, time-consuming aspects of your life go
away, we can give you a tool to help make your life easier, and healthier. The myCigna Mobile App gives you a simple way to
personalize, organize and access your important health information – on the go. It puts you in control of your health, so you can
get more out of life. Get the myCigna Mobile App from the App StoreSM or Google Play™.
Reminder: Anytime Service at Cigna
Did you know CIGNA ONE GUIDE is available 24 hours a day/7 days a week? You can speak to a live agent to assist you with
understanding your plan, get care, and get the most out of your plan.
2 MPS 2020-2021 Enrollment GuideIT’S EASY TO FIND QUALITY
PROVIDERS AND HOSPITALS.
You just have to know where to look.
Choosing a health care provider can be stressful. But with our Cigna Care Designation (CCD) and Centers of
Excellence (COE) programs, we make it easier. We identify higher-performing* providers and hospitals based
on their proven quality of care and cost efficiency. Then, we mark them with a symbol in our provider
directory so they’re easy to find.
Cigna Care Designation providers Choose with confidence.
Cigna reviews primary care providers (practitioners, To find a CCD provider:
internists and pediatricians), as well as providers › Log in to myCigna.com or the myCigna® App and
in 18 common specialties, including cardiology, select “Find Care & Costs”
dermatology and general surgery. Those who meet › Enter your search information
Cigna requirements for both care quality and cost
efficiency receive the CCD.
› Look for the CCD symbol under the provider’s name
To find a COE hospital:
Centers of Excellence hospitals
› Log in to myCigna.com or the myCigna App and
Cigna also reviews how successful a hospital is in select “Find Care & Costs”
treating 18 common conditions, such as heart conditions
and procedures, hip replacements and surgeries. When
› Select “Locations” and type “Center of Excellence”
in the search box to see a list of COE hospitals and
hospitals meet program criteria for cost and proven care
related procedures
effectiveness for a reviewed procedure or condition,
they earn the status of a COE for that condition or
› Look for the COE symbol under the hospital name
when searching by procedure
procedure. Our ratings are based on actual patient
outcomes, average lengths of stay and average costs
IMPORTANT NOTE:
we’ve gathered from outside sources.
The listing of a provider in the Cigna.com directory does not
guarantee that the provider participates in your specific health
plan network. To confirm if a provider is in-network for your plan,
use myCigna.com or the myCigna App. You can also call Cigna
customer service at the number on your Cigna ID card.
Offered by Cigna Health and Life Insurance Company or its affiliates.
*Providers and hospitals identified as having top results based on Cigna’s quality and cost-efficiency methodologies. Quality designations, cost-efficiency and other ratings reflect a partial
assessment of quality and cost efficiency and should not be the sole basis for decision making. They are not a guarantee of the quality of care that will be provided to individual patients. You are
encouraged to consider all relevant factors and consult with your physician when selecting a provider or hospital. Providers and hospitals are independent contractors solely responsible for care
delivered; providers and hospitals are not agents of Cigna.
Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details
of coverage, see your plan documents.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company (CHLIC), Connecticut General Life Insurance
Company, and HMO or service company subsidiaries of Cigna Health Corporation, including including Cigna HealthCare of Arizona, Inc., Cigna HealthCare of California, Inc., Cigna HealthCare of Colorado, Inc.,
Cigna HealthCare of Connecticut, Inc., Cigna HealthCare of Florida, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Indiana, Inc., Cigna HealthCare of St. Louis, Inc., Cigna
HealthCare of North Carolina, Inc., Cigna HealthCare of New Jersey, Inc., Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of Tennessee, Inc. (CHC-TN), and Cigna HealthCare of Texas, Inc. Policy forms:
OK – HP-APP-1 et al., OR – HP-POL38 02-13, TN – HP-POL43/HC-CER1V1 et al. (CHLIC); GSA-COVER, et al. (CHC-TN). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
926747 a 10/19 ©2019 Cigna. Some content provided under license.
MPS 2020-2021 Enrollment Guide 3WELLNESS INCENTIVE PROGRAM
July 1, 2020 – June 30, 2021
Up to 40 winners a month will be selected to win a $100 gift card!
1. Complete the Cigna online health assessment and earn 100 points.
2. Complete activities such as free preventive exams or telephonic health
coaching for 100 points each.
3. Get entered into a drawing to win a $100 gift card if you have at least 100 points.
The more points you earn, the more chances you have to win.
All employees and spouses on the medical plan are eligible to participate. Those who have earned 300 points by June 30, 2021 will
be entered into the grand prize drawing for one of three $1,000 gift cards.
Check your point status on mycigna.com by simply logging in and selecting “Incentive Awards” under the “Wellness” heading.
Goal Description Points
Complete your personalized health assessment Go to mycigna.com, select “My health assessment” underneath the “Wellness” heading 100
and complete it with your biometric numbers. This is a confidential questionnaire
that asks you about your well-being and provides a personalized assessment of your
current health and should take less than 10 minutes to complete.
Complete a personalized biometric screening Know your numbers. Work with your healthcare provider to complete your screening 100
for blood pressure, cholesterol, blood sugar and body mass index (BMI). Submitted via
claims, Quest, or onsite screening.
Telephonic Coaching: Work one-on-one with a health coach on a health goal. Automatically updated by 100
Talk to a coach and achieve a health goal coach.
Telephonic Coaching: Quitting tobacco is one of the most important things you can do for better health. 100
Get help improving my lifestyle habits – Tobacco A health coach can help you take that critical step today. Automatically updated by
Cessation coach.
Telephonic Coaching: If you’re looking to get to your healthy weight, a health coach can set realistic goals 100
Get help improving my lifestyle habits - Weight and help you work toward achieving each one. Automatically updated by coach.
Telephonic Coaching: Lower your stress levels and raise your happiness levels by creating a personal stress 100
Get help improving my lifestyle habits - Stress management plan with a health coach. Automatically updated by coach.
Telephonic Coaching: Work one-on-one with a health coach on a long-term health problem such as 100
Achieve a goal to overcome a chronic health congestive heart failure, depression, diabetes, low back pain, etc. Automatically
problem updated by health coach.
Get my preventive well visit A preventive exam that’s used to reinforce good health, address potential and chronic 100
(preventive exam) problems. Verified by claims.
Get my annual OB/GYN exam A preventive exam that can identify early ovarian and cervical cancers, HPV (human 100
(preventive exam) papillomavirus), breast cancer and more. Verified by claims.
Get a mammogram Breast cancer can be found using mammogram tests. Verified by claims. 100
(preventive exam)
Get a colon cancer screening Colon cancer can be treatable when detected early. Verified by claims. 100
(preventive exam)
Get a cervical cancer screening Pap and HPV tests can detect changes that lead to cervical cancer. Verified by claims. 100
(preventive exam)
Get a prostate cancer screening A prostate screening can detect changes that lead to prostate cancer. Verified by 100
(preventive exam) claims.
Earn 1,000 SmartDollar points Participate in the step-by-step plan with SmartDollar platform to reach your financial 100
goals. Once you earn 1,000 points, log in to mycigna.com and self-report your success.
Complete 9 lessons of the 16-week Cigna Omada is a digital lifestyle change program that inspires healthy habits that last. Must 100
Diabetes Prevention Program be accepted into the program. Automatically updated.
Reduce your weight by 5% with the Cigna Reduce your start weight by 5%. Losing 5 percent or more of your body weight can 100
Diabetes Prevention Program lower your risk of cancer, heart disease, stroke, and diabetes. Automatically updated.
Completed a preventive dental cleaning You should see your dentist at least once per year for a free exam to check for any 100
problems in the teeth or gums. After your cleaning, log in to mycigna.com and record
your exam date.
Get started with telephonic health coaching by calling 1-855-626-0711 today!
* If you have an impairment or disability that makes you unable to participate in any of the program events, activities or goals, you may be entitled to a reasonable accommodation for
participation, or an alternative standard for rewards, contact 1.800.Cigna24.
This is an entirely voluntary program; however, employees who choose to participate in the wellness program may receive an incentive of a monetary amount or a wellness prize item
that will be identified and communicated during any and all health campaigns.
4 MPS 2020-2021 Enrollment GuideYOUR BABY ISN’T
YOUR ONLY REWARD
Take part in the Cigna Healthy Pregnancies, Healthy Babies progam
and earn an award.
You’re pregnant.
You’re going to be choosing a name. Looking for a doctor for your baby.
And seeing big changes – to your body and your life.
Where do you start?
Sign up for the Cigna Healthy Pregnancies, Healthy Babies® program,
designed to help you and your baby stay healthy during your pregnancy and Get rewarded for a
in the days and weeks after your baby’s birth. good decision.
Cigna Healthy Pregnancies,
Find support early and often. Healthy Babies is part of an
› Tell us about you and your pregnancy so we can meet your needs. incentive awards program. So,
when you take part and finish
› Ask us anything – our pregnancy coaches have nursing experience and
the program, you’ll be eligible
are here to support you during your whole pregnancy.
to receive a:**
› Get a pregnancy journal, with information, charts and tools to help you
$250 gift card
have a happy nine months.
Learn as much as you want.
if you enroll in the
As a Cigna customer you also have access to our Health Information Line, first trimester.
where you can get live support 24 hours a day, 7 days a week. Just call the
Or
number on your Cigna ID card to:
$125 gift card
› Talk to a nurse who can help you with everything from tips on how to
handle your discomfort during pregnancy, to birthing classes and
maternity benefits.
› Listen to an audio library of health topics. if you enroll in the
second trimester.
Visit myCigna.com for tools to help you track your pregnancy week by
week, prepare for delivery and care for your baby.
Enroll today. Call
The Cigna Healthy Pregnancy™ App is another resource available to you. This 800.615.2906
valuable resource allows you to easily track your pregnancy and learn about
pregnancy topics, and engage in the Cigna Healthy Pregnancies, Healthy
Babies program to help you stay healthy every step of the way. Download the
app now,* available on Google Play™ or the App Store®.
883096 a 03/18
MPS 2020-2021 Enrollment Guide 5For eligible Mesa Public Schools employees
and their covered dependents
If you or your covered dependents are at risk for type 2 diabetes
or heart disease, and enrolled in our Cigna health plan, Mesa
Public Schools will cover the entire cost of the program.
omadahealth.com/mpsaz
6 MPS 2020-2021 Enrollment GuideDENTAL PLANS
The district will continue to offer the choice of two dental plans Cigna CARE DHMO and Cigna PPO for you and your eligible
dependents.
The Cigna CARE DHMO plan requires you to see In-Network dentists and offers lower rates and no maximum annual limits. If you
are a new subscriber: You must select a provider by calling Cigna before using any services. If you are a current subscriber
and would like to change your provider, please call Cigna at 1-800-244-6224.
The Cigna PPO allows you to choose in- or out-of-network providers and has deductibles, coinsurance and maximum annual
coverage limits.
Highlights of the Dental Plan Options Offered by Mesa Public Schools
Benefit CIGNA CIGNA
Dental Care DHMO Plan Dental PPO Plan
You Pay: You Pay:
In-Network
In-Network CIGNA Advantage Out-of-Network
Dental Provider Choice Participants must use an Participants may use an in-network or out-of-network dentist
in-network dentist or specialist
Dental Plan Annual Maximum Unlimited $1,000 per person
Annual Deductible
• For one person $0 $25
• For your family $0 $75
Diagnostic and Preventive Services Scheduled amounts no copays
• Office visit $0 20%
• Oral Exams $0 of allowed amount plus
• Cleanings $0 $0 with no deductible any charges in excess of
• X-rays $0 the allowed amount,
• Fluoride treatment $0 after deductible
• Sealants $17 per tooth
Basic Treatment Scheduled amounts
• Extractions, simple $53 20%
• Fillings (amalgam) $17 to $35 per tooth of allowed amount plus
• Fillings (composite for molars) $47 to $115 per tooth 20% after deductible any charges in excess of
• Root Canal (molar) $530 the allowed amount,
• Periodontics (scaling, root planing) $115 per quadrant after deductible
• Osseous Surgery $350 to $595
Major Treatment Scheduled amounts 50%
• Crown $370 to $515 of allowed amount plus
• Full denture (upper or lower) $575 50% after deductible any charges in excess of
• Partial denture(upper or lower) $430 -$670 the allowed amount,
after deductible
Orthodontia 50%
• Adults Not covered of allowed amount plus
• Children (to age 19) Scheduled amounts any charges in excess of
50% after deductible the allowed amount,
after deductible
Lifetime Orthodontia Benefit Not covered
• Adults Scheduled Amounts
• Children (to age 19) $1,000
Additional Benefits 20%
• Specialist Services Scheduled Amounts of allowed amount plus
• General anesthesia (first 30 minutes) $190 20% after deductible any charges in excess of
the allowed amount,
after deductible
MPS 2020-2021 Enrollment Guide 7VISION BENEFITS
Mesa Public Schools provides vision coverage at no cost for eligible employees through Vision Service Plan (VSP). Employees may
purchase vision coverage for their dependents. Vision coverage includes benefits for eye examinations, lenses, frames and contact
lenses.
A Closer Look at Your Vision Benefits
Benefit Description Vision Plan Learn more about your
Eye Exam payable every: 12 months vision coverage at vsp.com.
KidsCare: Children have two exams • Find a VSP doctor call VSP at
Lenses payable every: 12 months 1-800-877-7195
Frames payable every: 24 months • Visit www.vsp.com and click on
KidsCare: Frames for Children 12 months the Members tab.
In-Network Vision Provider • Sign up for a user account and get
Exam Copayment: $15.00 the most out of your benefits when
you log in-view your personalized
Allowances benefits, look at your claim history,
Wholesale frame allowance: $100.00 and much more.
Retail frame allowance: $180.00
Elective contact lenses: $130.00
Lens Options: Single vision lined bifocal and lined
trifocal lenses, as well as polycarbonate
lenses for children, are included in
prescription glasses. Progressive lenses
will incur an additional copay (see
Benefits website for details).
Vision Plan’s Reimbursement for Out-of-Network Provider
Exam, up to: $50.00
Single Vision Lenses, up to: $50.00
Bifocal Lenses, up to: $75.00
Trifocal Lenses, up to: $100.00
Lenticular Lenses, up to: $125.00
Frame, up to: $70.00
Elective Contact Lenses, up to: $105.00
8 MPS 2020-2021 Enrollment GuideFLEXIBLE SPENDING ACCOUNTS If there are funds remaining in an FSA upon termination of employment (or other COBRA qualifying event), continued participation in the account may be elected and a monthly premium must be made through COBRA. FSA COBRA premium payments will be made with after-tax contributions only. The coverage continuation for the FSA will be offered only for the remainder of the plan year in which the Qualifying Event occurs. If an employee does not elect COBRA, then any balances are forfeited unless claims were incurred before the termination date. HEALTH SAVINGS ACCOUNTS If you have an HSA account at the time of your termination with Mesa Public Schools, the funds are yours to use for qualified expenses. HSA Bank will convert your account to a non-group account and send you a new HSA card with a VISA logo. You will be responsible for any fees that HSA Bank charges to have the account. If you wish to use your HSA funds to cover your monthly COBRA premium, you must do so through HSA Bank at mycigna.hsabank.com. If you need assistance, please call 480-472-7222. LIFE INSURANCE BENEFITS Life insurance in effect upon termination of employment (or another COBRA-qualifying event) may be ported or converted. Porting or converting allows you to take your coverage with you once you are no longer eligible for the group plan sponsored by the district. You must complete and submit the application to Sun Life within 31 days of status change. Please contact Sun Life at 1-800-247-6875 for additional information on life insurance portability and conversion. EMPLOYEE ASSISTANCE PROGRAM All employees are eligible to receive confidential counseling benefits through the district’s Employee Assistance Program (EAP). You and your eligible family members are automatically covered and receive up to 8 counseling sessions per event per person per year at no cost to you. The EAP provides confidential, personal assessments, and referral services through EAP Preferred. You can confidentially discuss your situation and find resources and information for personal difficulties such as: • Family or marital problems • Eating disorders such as anorexia • Parenting concerns • Conflicts at work • Grief over the death of a loved one or other losses • Job stress • Drug and alcohol dependence • Crisis Situations • Emotional difficulties such as depression, anxiety and guilt EAP Preferred provides a range of legal and financial services to help with balancing life at Work and Home. Visit eappreferred.com for more information. MPS 2020-2021 Enrollment Guide 9
FOR HELP OR INFORMATION
When you need information, please refer to the contacts listed in the following Quick Reference Chart:
QUICK REFERENCE CHART
INFORMATION NEEDED WHOM TO CONTACT
Medical Plans Claims Administrator CIGNA HealthCare (CIGNA)
• Claim Forms (Medical) Open Access Plus (OAP or OA Plus) Customer Service:
• Medical Plan Claims and Appeals 1-800-244-6224 (1-800-CIGNA24)
• Eligibility for Coverage HDHP Customer Service:
1-800-244-6224 (1-800-CIGNA24)
• Plan Benefit Information
Website: www.mycigna.com
• Summary of Benefits and Coverage (SBC)
Claim Submittal Address:
CIGNA
MPS Group Number: 3333634
P. O. Box 182223
Chattanooga, TN 37422-7223
Appeals Submittal Address:
CIGNA Healthcare
MPS Group Number: 3333634
National Appeals Unit
P. O. Box 188011
Chattanooga, TN 37422
Medical Plans Provider Network CIGNA HealthCare (CIGNA)
(called Open Access Plus or OAP or OA Plus) Open Access Plus (OAP or OA Plus) Customer Service:
• OA Plus Medical Network Provider Directory for the 1-800-244-6224 (1-800-CIGNA24)
CIGNA Open Access Plus Network HDHP Customer Service: 1-800-244-6224
• Additions/Deletions of Network Providers Website: www.cigna.com and select the Open Access Plus
• (Always check with the Network before you visit a Network
provider to be sure they are still contracted and will CAUTION: Use of a non-network hospital, facility or Health Care
give you the discounted price) Provider could result in you having to pay a substantial balance
on the provider’s billing (see definition of “balance billing” in the
Definition chapter of this document). Your lowest out of pocket
costs will occur when you use In-Network providers.
Utilization Management (UM) Program CIGNA HealthCare (CIGNA)
• Pre-authorization (precertification) of Admissions and Open Access Plus (OAP or OA Plus) Customer Service:
Medical Services 1-800-244-6224
• Case Management HDHP Customer Service: 1-800-244-6224
• Appeals of UM decisions
Prescription Drug Plan CIGNA HealthCare (CIGNA)
• ID Cards Customer Service: 1-800-244-6224
• Retail Network Pharmacies Specialty Drug Customer Service: 1-800-285-4812
• Mail Order (Home Delivery) Pharmacy CIGNA Home Delivery Pharmacy
• Prescription Drug Information Customer Service: 1-800-285-4812
P. O. Box 1019
• Formulary of Preferred Drugs Horsham, PA 19044
• Precertification of Certain Drugs
Website: www.mycigna.com
• Direct Member Reimbursement (for Non-network
Quit Today Smoking Cessation Program:
retail pharmacy use)
Call 1-800-224-6224 to enroll
• Specialty Drug Program: Precertification and Ordering
10 MPS 2020-2021 Enrollment GuideQUICK REFERENCE CHART
INFORMATION NEEDED WHOM TO CONTACT
Behavioral Health Program CIGNA HealthCare (CIGNA)
for all medical plan options Customer Service: 1-800-244-6224 (1-800-CIGNA24)
• Mental Health and Substance Abuse Services and Website: www.mycigna.com or
Providers www.cignabehavioralhealth.com
• Precertification of Certain Behavioral Health Services
• Behavioral Health Claims and Appeals
Healthy Pregnancy Healthy Babies Program Healthy Pregnancy Healthy Babies Program
• The CIGNA Healthy Pregnancies, Healthy Babies® from CIGNA
program can help, providing education and support Call 1-800-244-6224
throughout your entire pregnancy – and after, if
Website: www.mycigna.com
you complete the program, you could be eligible to
receive an incentive of up to $250.
• Healthy Pregnancy Healthy Babies is a collection of
CIGNA benefits and an educational mailing available
to you as part of your CIGNA HealthCare administered
medical plan of benefits. The mailing includes a list
of web resources, list of pregnancy related topics in
the 24-hour Health Information Line audio library, a
magazine, and brochures from the March of Dimes.
Your Health First Program CIGNA Your Health First
• Free health support services. CIGNA’s Your Health The phone number is on the back of your ID card or
First health experts trained as nurses, pharmacists, call 1-800-244-6224.
behavioral clinicians and health educators. They’re
available Monday through Saturday to speak with
you one-on-one. They can help you find the best
and most cost-effective health professionals and
services in our area. You can call to ask questions
about ways
to improve your health and get additional information
about medication and treatment options that your
doctor may have mentioned.
• Improve your lifestyle with effective stress, tobacco
or weight management.
• Better manage conditions such as depressions,
asthma, diabetes and more
• Make the best decisions about treatment for
common conditions like low back pain or heart
disease.
• Find ways to reduce health care costs by savings
money on medications, treatments or other health
related expenses.
MPS 2020-2021 Enrollment Guide 11QUICK REFERENCE CHART
INFORMATION NEEDED WHOM TO CONTACT
Cancer Treatment Support Program Cancer Treatment Support Program from CIGNA
• • CIGNA’s Cancer Care Support Program offers Call 1-800-244-6224
people with cancer assistance from Cigna nurse Website: www.mycigna.com
coaches as they make critical decisions regarding their
medical care, treatment and recovery.
• The CIGNA Cancer Support Program provides access
to a specially trained cancer nurse to assist you one-
on-one. Your nurse can help you understand your
diagnosis, medications, treatment options identified
by your doctor and help answer any questions you
may have. In addition, CIGNA can help you coordinate
your care, understand your insurance coverage, and
find additional resources like local support groups and
facilities.
Dental PPO Plan Claims Administrator CIGNA Dental PPO
• Dental PPO Network Provider Directory Customer Service: 1-800-244-6224 (1-800-CIGNA24)
• Dental PPO Plan Claims and Appeals MPS Group Number: 3333634
Website: www.mycigna.com
Dental HMO Plan (Dental Care HMO) CIGNA Dental Care HMO
• The insured Dental HMO plan benefits are NOT fully Customer Service: 1-800-244-6224 (1-800-CIGNA24)
described in this document. Contact the Employee MPS Group Number: 3333634
Benefits Office for further information.
Website: www.mycigna.com
Locate Provider Website: www.cigna.com and select the
Cigna Dental Care HMO
Vision PPO Plan Claims Administrator Vision Service Plan (VSP)
• Vision PPO Network and Provider Directory Customer Service: 1-800-877-7195
• Vision PPO Plan Claims and Appeals MPS Group Number: 12-140015
Website: www.vsp.com
Health Savings Account (HSA) Bank Contact CIGNA Customer Service: 1-800-244-6224
Website: www.mycigna.com
COBRA Administrator Mesa Public Schools
• Information About Coverage ATTN: COBRA Specialist
• Adding or Dropping Dependents 63 East Main Street Suite 101
Mesa, AZ 85201
• Cost of COBRA Continuation Coverage
Phone: 480-472-7222
• COBRA Premium payments Secure Fax: 480-472-0370
• Second Qualifying Event and Disability Notification
Employee Benefits Office Employee Benefits
Plan Administrator 63 East Main Street Suite 101
HIPAA Privacy and Security Officer Mesa, AZ 85201
• Medicare Part D Notice of Creditable Coverage Phone: 480-472-7222
• HIPAA Notice of Privacy Practice Secure Fax: 480-472-0370
Email: benefits@mpsaz.org
12 MPS 2020-2021 Enrollment GuideQUICK REFERENCE CHART
INFORMATION NEEDED WHOM TO CONTACT
Life Insurance and Accidental Death and Sun Life
Dismemberment Insurance 1-800-247-6875
• Portability and Conversion MPS Group Number: 213993
Website: www.sunlife.com/us
Flex Benefits Claims Administrator CIGNA Healthcare
• Health FSA both General Purpose and Limited Customer Service: 1-800-244-6224 (1-800-CIGNA24)
Purpose for HDHP participants Website: www.mycigna.com
• Dependent Care FSA
Plan Administrator/Plan Sponsor Governing Board of the
Mesa Unified School District #4
63 East Main Street, Suite 101
Mesa, AZ 85201
Phone: 480-472-7222
Fax: 480-472-0370
Email: benefits@mpsaz.org
Web Site: www.mspaz.org/benefits
MPS 2020-2021 Enrollment Guide 13IMPORTANT NOTICES
This section contains important employee benefit program notices of interest to you and your family. Please share
this information with your family members. Some of the notices in this document are required by law and other
notices contain helpful information. These notices are updated from time to time and some of the federal notices
are updated each year. Be sure you are reviewing an updated version of this important notices document.
Notice of MPS Privacy Practices
HIPAA Privacy pertains to the following group health plan benefits sponsored by Mesa Public Schools:
• Self-funded medical, prescription, dental and vision plans
• Medical reimbursement account provisions of the flexible spending account (both the general purpose and limited
purpose health flex plans)
• COBRA Administration
This Plan’s HIPAA Notice of Privacy Practices explains how the group health plan uses and discloses your personal health
information. You are provided a copy of this Notice when you enroll in the Plan. To obtain a free copy of this Plan’s HIPAA Notice
of Privacy Practices for the above noted group health plan benefits, write or call the Employee Benefits Department at 63 E. Main
Street #101, Mesa AZ 85201-7422, (480) 472-7222 or access your benefits website at www.mpsaz.org/benefits/publications.
WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA)
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:
• All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles, copayment and coinsurance applicable to other medical and
surgical benefits provided under the various medical plans offered by the District. For more information, refer to your medical Plan
Document or call the Employee Benefits Department at (480) 472-7222.
NEWBORN’S AND MOTHER’S HEALTH PROTECTION ACT
Under federal law, group health plans and health insurance issuers generally may not restrict benefits for any hospital length of
stay in connection with childbirth for the mother of a newborn child to less than 48 hours following a normal vaginal delivery,
or less than 96 hours following a cesarean section. However, the Plan may pay for a shorter stay if the attending Physician (e.g.,
Physician, or Health Care Practitioner), after consultation with the mother, discharges the mother or newborn earlier.
Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or
96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, the
Plan may not, under federal law, require that a Physician or other Health Care Practitioner obtain authorization for prescribing a
length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs,
you may be required to obtain precertification. For information on precertification for a length of stay longer than 48 hours for
vaginal birth or 96 hours for C-section, contact the Utilization Management program to pre-certify the extended stay. If you have
questions about this Notice, contact the Employee Benefits Department at (480) 472-7222.
TAX INFORMATION FOR FAILURE TO MAINTAIN MEDICAL PLAN COVERAGE
If you choose not to be covered by one of Mesa Public Schools medical plan options, remember that you must maintain medical
plan coverage elsewhere or you can purchase health insurance through a Marketplace (www.healthcare.gov), typically at the
Marketplace annual enrollment in the fall each year. In December 2017 Congress passed a new law (the Tax Cuts and Jobs Act) that
reduced the Individual Mandate penalty to zero starting in 2019. This means that starting in 2019 there will no longer be a federal
Individual Mandate penalty for failure to maintain medical plan coverage.
Note that if you are a resident of the District of Columbia or certain states, such as Massachusetts, New Jersey, Vermont, California
or Rhode Island, you may be subject to a state income tax penalty if you fail to maintain medical plan coverage that meets that
state’s minimum coverage requirements. Consult with your own state’s insurance department for information on whether your
state has adopted or will be adopting a state Individual Mandate penalty.
14 MPS 2020-2021 Enrollment GuideMEDICARE NOTICE OF CREDITABLE COVERAGE If you or your eligible dependents are currently Medicare eligible, or will become Medicare eligible during the next 12 months, you need to be sure that you understand whether the prescription drug coverage that you elect under the Medical Plan options available to you are or are not creditable with (as valuable as) Medicare’s prescription drug coverage. To find out whether the prescription drug coverage under the Medical plan options offered by the District are or are not creditable you should review the Plan’s Medicare Part D Notice of Creditable Coverage (located in this document) and also available from Employee Benefits or on the benefits website at www.mpsaz.org/benefits/publications. AVAILABILITY OF SUMMARY HEALTH INFORMATION: THE SUMMARY OF BENEFIT AND COVERAGE (SBC) DOCUMENT(S) The health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. In accordance with law, our plan provides you with a Summary of Benefits and Coverage (SBC) to help you understand and compare medical plan benefits. The SBC summarizes and compares important information including, what is covered, what you need to pay for various benefits, what is not covered, and where to get answers to questions. SBC documents are updated when there is a change to the benefits information displayed on an SBC. To get a free copy of the most current Summary of Benefits and Coverage (SBC) documents for our medical plan options, go to www.mpsaz.org/benefits or contact the Employee Benefits Department at (480) 472-7222. IMPORTANT REMINDER TO PROVIDE THE PLAN WITH THE TAXPAYER IDENTIFICATION NUMBER (TIN) OR SOCIAL SECURITY NUMBER (SSN) OF EACH ENROLLEE IN A HEALTH PLAN Employers are required by law to collect the taxpayer identification number (TIN) or social security number (SSN) of each medical plan participant and provide that number on reports that will be provided to the IRS each year. Employers are required to make at least two consecutive attempts to gather missing TINs/SSNs. If a dependent does not yet have a social security number, you can go to this website to complete a form to request a SSN: http://www.socialsecurity.gov/online/ss-5.pdf. Applying for a social security number is FREE. If you have not yet provided the social security number (or other TIN) for each of your dependents that you have enrolled in the health plan, please contact the Employee Benefits Department at (480) 472-7222. PATIENT PROTECTION RIGHTS AFFORDABLE CARE ACT If you are enrolled in any of the District’s medical plans, you do not need prior authorization from any other person (including a primary care provider) to obtain access to obstetrical or gynecological care from a health care professional in the 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 making referrals. Also, the District’s medical plans do not require the selection or designation of a primary care provider (PCP). You can visit any network or non-network health care provider, however, payment by the Plan may be less for the use of a non-network provider. MPS 2020-2021 Enrollment Guide 15
SPECIAL ENROLLMENT EVENT
IMPORTANT: Generally, you will not be allowed to change your benefit elections or add/delete dependents until the District’s
next open enrollment open enrollment period unless you have a Special Enrollment Event as outlined below:
a. Loss of Other Coverage Event: 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 toward your or your dependents’ other coverage). However, you must request enrollment within 31
days of the date of your dependents’ other coverage ends (or after the employer stops contributing towards the other
coverage). *
b. Marriage, Birth, Adoption Event: In addition, if you have a new dependent as a result of marriage, birth, adoption,
or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request
enrollment within 31 days of the date of the marriage, birth, adoption, or placement for adoption. *
c. Medicaid/CHIP Event: You and your eligible dependents may also enroll in this plan if you (or your dependents):
• have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and you (or your dependents)
lose eligibility for that coverage. However, you must request enrollment within 60 days after the Medicaid or CHIP
coverage ends.
• become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment
within 60 days after you (or your dependents) are determined to be eligible for such assistance.
To request special enrollment or obtain more information, contact the Employee Benefits Department at (480) 472-7222.
* Note the District will consider the date of the eligibility for the special enrollment event as the first day for purposes of counting
towards the 31-day special enrollment deadline.
KEEP THE PLAN NOTIFIED OF CHANGES
You or your Dependents must promptly furnish to the Employee Benefits Department information regarding change of name,
address, marriage, divorce or legal separation, death of any covered family member, birth and change in status of a Dependent
Child, Medicare enrollment or disenrollment, an individual no longer meeting the eligibility provisions of the Plan, or the existence
of other coverage. Proof of legal documentation will be required for certain changes.
Notify the Plan of any of these changes within 31 days by contacting the Employee Benefits Department at (480) 472-7222.
Important Notices Attached
The following pages include important notices for you and your family:
• HIPAA Privacy Notice
• Medicare Part D Notice
• Notice about Premium Assistance with Medicaid and CHIP
16 MPS 2020-2021 Enrollment GuideMESA PUBLIC SCHOOLS EMPLOYEE BENEFIT TRUST GROUP HEALTH PLAN
HIPAA PRIVACY NOTICE
Purpose of This Notice
This Notice describes how medical information about you may be used and disclosed and
how you may obtain access to this information. Please review this information carefully.
THIS NOTICE IS REQUIRED BY LAW.
The Mesa Public Schools Employee Benefit Trust Group Health Plan includes these self-funded benefit programs: medical plans
including outpatient prescription drug benefits, dental PPO plan, vision plan, health flexible spending reimbursement accounts,
health savings account administration and COBRA administration, (the “Plan”). The Plan is required by law to take reasonable
steps to maintain the privacy of your personally identifiable health information (called Protected Health Information or PHI)
and to inform you about the Plan’s legal duties and privacy practices with respect to protected health information including:
1. The Plan’s uses and disclosures of PHI,
2. Your rights to privacy with respect to your PHI,
3. The Plan’s duties with respect to your PHI,
4. Your right to file a complaint with the Plan and with the Secretary of the U.S. Department of Health and Human Services,
5. The person or office you should contact for further information about the Plan’s privacy practices, and
6. To notify affected individuals following a breach of unsecured protected health information.
The Plan Sponsor has amended its Plan documents to protect your PHI as required by Federal law.
PHI use and disclosure by the Plan is regulated by the Health Insurance Portability and Accountability Act, (HIPAA). You may find
these rules in Section 45 of the Code of Federal Regulations, Parts 160 and 164. The regulations will supersede this Notice if there
is any discrepancy between the information in this Notice and the regulations. The Plan will abide by the terms of the Notice
currently in effect. The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective
for all PHI it maintains.
You may receive a Privacy Notice from the companies who offer Plan participants insured health care services, such as the Dental
HMO plan. Each of these notices will describe your rights as it pertains to that plan and in compliance with the federal regulations
of HIPAA. This Privacy Notice, however, pertains to your Protected Health Information related to the Mesa Public Schools
Employee Benefit Trust Group Health Plan (the “Plan”) and outside companies contracted to help administer Plan benefits, also
called “Business Associates.”
Effective Date
The effective date of this Notice is March 26, 2019, and this notice replaces notices previously distributed to you.
Privacy Officer
The Plan has designated a Privacy Officer to oversee the administration of privacy by the Plan, to receive complaints, and to be
able to provide further information about matters covered by this Notice. The Privacy Officer may be contacted at:
Benefits Director, MPS Employee Benefits Department
63 E. Main St. #101, 2nd Floor
Mesa, AZ 85201-7422
Phone: 480-472-7222 • Fax: 480-472-0370
MPS 2020-2021 Enrollment Guide 17YOUR PROTECTED HEALTH INFORMATION
The term “Protected Health Information” (PHI) includes all information related to your past, present or future health condition(s)
that individually identifies you or could reasonably be used to identify you and is transferred to another entity or maintained by
the Plan in oral, written, electronic or any other form.
PHI does not include health information contained in employment records held by your employer in its role as an employer,
including but not limited to health information on disability, work-related illness/injury, sick leave, Family or Medical Leave (FMLA),
life insurance, dependent care flexible spending account, drug testing, etc.
WHEN THE PLAN MAY DISCLOSE YOUR PHI
Under the law, the Plan may disclose your PHI without your written authorization in the following cases:
• At your request. If you request it, the Plan is required to give you access to your PHI in order to inspect it and copy it.
• As required by an agency of the government. The Secretary of the Department of Health and Human Services may
require the disclosure of your PHI to investigate or determine the Plan’s compliance with the privacy regulations.
• For treatment, payment or health care operations. The Plan and its Business Associates will use your PHI (except
psychotherapy notes in certain instances as described below) without your consent, authorization or opportunity to
agree or object in order to carry out treatment, payment, or health care operations.
The Plan does not need your consent or authorization to release your PHI when you request it, a government agency requires it, or
the Plan uses it for treatment, payment or health care operations.
The Plan Sponsor has amended its Plan documents to protect your PHI as required by Federal law. The Plan may disclose PHI to
the Plan Sponsor for purposes of treatment, payment and health care operations in accordance with the Plan amendment. The
Plan may disclose PHI to the Plan Sponsor for review of your appeal of a benefit or for other reasons related to the administration
of the Plan
DEFINITIONS AND EXAMPLES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
Treatment is the provision, coordination or management of health care and related services. It also includes
but is not limited to coordination of benefits with a third party and consultations and referrals between one
Treatment is or more of your health care providers.
health care.
• For example: The Plan discloses to a treating specialist the name of your treating primary care
physician so the two can confer regarding your treatment plan.
Payment includes but is not limited to making payment for the provision of health care, determination of
eligibility, claims management, and utilization review activities such as the assessment of medical necessity
Payment is and appropriateness of care.
paying claims for
health care and • For example: The Plan tells your doctor whether you are eligible for coverage or what percentage
related activities. of the bill will be paid by the Plan. If we contract with third parties to help us with payment, such
as a claims payer, we will disclose pertinent information to them. These third parties are known as
“Business Associates.”
Health care operations includes but is not limited to quality assessment and improvement, patient safety
activities, business planning and development, reviewing competence or qualifications of health care
Health Care professionals, underwriting, enrollment, premium rating and other insurance activities relating to creating
Operations or renewing insurance contracts. It also includes disease management, case management, conducting or
keep the Plan arranging for medical review, legal services and auditing functions including fraud and abuse compliance
operating programs and general administrative activities.
soundly. • For example: The Plan uses information about your medical claims to refer you to a health
care management program, to project future benefit costs or to audit the accuracy of its claims
processing functions.
18 MPS 2020-2021 Enrollment GuideWHEN THE DISCLOSURE OF YOUR PHI REQUIRES YOUR WRITTEN AUTHORIZATION
Generally, the Plan will require that you sign a valid authorization form in order to use or disclose your PHI other than:
• When you request your own PHI
• A government agency requires it, or
• The Plan uses it for treatment, payment or healthcare operation
• You have the right to revoke an authorization
Although the Plan does not routinely obtain psychotherapy notes, generally, an authorization will be required by the Plan
before the Plan will use or disclose psychotherapy notes about you. Psychotherapy notes are separately filed notes about your
conversations with your mental health professional during a counseling session. They do not include summary information about
your mental health treatment. However, the Plan may use and disclose such notes when needed by the Plan to defend itself
against litigation filed by you.
The Plan generally will require an authorization form for uses and disclosure of your PHI for marketing purposes (meaning a
communication that encourages you to purchase or use a product or service) if the Plan receives direct or indirect financial
remuneration (payment) from the entity whose product or service is being marketed. The Plan generally will require an
authorization form for the sale of Protected Health Information if the Plan receives direct or indirect financial remuneration
(payment) from the entity to which the PHI is sold. The Plan does not intend to engage in fundraising activities.
USE OR DISCLOSURE OF YOUR PHI WHERE YOU WILL BE GIVEN AN OPPORTUNITY TO
AGREE OR DISAGREE BEFORE THE USE OR RELEASE
Disclosure of your PHI to family members, other relatives and your close personal friends without your written consent or
authorization is allowed if:
• The information is directly relevant to the family or friend’s involvement with your care or payment for that care, and
• You have either agreed to the disclosure or have been given an opportunity to object and have not objected.
Under this Plan your PHI will automatically be disclosed to internal employer departments as outlined below. If you disagree with
this automatic disclosure by the Plan you may contact the Privacy Officer to request that such disclosure not occur without your
written authorization:
• In the event of your death while you are covered by this Plan, when the Plan is notified it will automatically communicate
this information to the following internal departments: Human Resources, Benefits and payroll.
• In the event the Plan is notified of a work-related illness or injury, the Plan will automatically communicate this
information to the Risk Management Manager, and Benefits/Risk Management Specialist to allow the processing of
appropriate paperwork.
• In the event the Plan is notified of a condition that may initiate a short-term disability benefit, the Plan will automatically
communicate this information to the Benefits Specialist to allow the processing of appropriate paperwork.
• In the event the Plan is notified of a situation where it may be possible to initiate a medical leave under the Family and
Medical Leave Act (FMLA) benefit, the Plan will automatically communicate this information to the FMLA Coordinator in
the Human Resources department to allow the processing of appropriate FMLA paperwork.
Note that PHI obtained by the Plan Sponsor’s employees through Plan administration activities will NOT be used for
employment related decisions.
USE OR DISCLOSURE OF YOUR PHI WHERE CONSENT,
AUTHORIZATION OR OPPORTUNITY TO OBJECT IS NOT REQUIRED
In general, the Plan does not need your written authorization to release your PHI if required by law or for public health and safety
purposes. The Plan and its Business Associates can use and disclose your PHI without your written authorization (in compliance
with section 164.512) under the following circumstances:
1. When required by law.
2. When permitted for purposes of public health activities. This includes reporting product defects, permitting product
recalls and conducting post-marketing surveillance. PHI may also be used or disclosed if you have been exposed to a
communicable disease or are at risk of spreading a disease or condition, if authorized by law.
MPS 2020-2021 Enrollment Guide 193. To a school about an individual who is a student or prospective student of the school if the Protected Health Information
that is disclosed is limited to proof of immunization, the school is required by State or other law to have such proof of
immunization prior to admitting the individual and the covered entity obtains and documents the agreements to this
disclosure from either a parent, guardian or other person acting in loco parentis of the individual, if the individual is an
unemancipated minor; or the individual, if the individual is an adult or emancipated.
4. When authorized by law to report information about abuse, neglect or domestic violence to public authorities if a reasonable
belief exists that you may be a victim of abuse, neglect or domestic violence. In such case, the Plan will promptly inform
you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose
of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made.
Disclosure may generally be made to the minor’s parents or other representatives, although there may be circumstances
under Federal or State law when the parents or other representatives may not be given access to the minor’s PHI.
5. To a public health oversight agency for oversight activities authorized by law. These activities include civil, administrative
or criminal investigations, inspections, licensure or disciplinary actions (for example, to investigate complaints against
providers) and other activities necessary for appropriate oversight of government benefit programs (for example, to
investigate Medicare or Medicaid fraud).
6. When required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a
subpoena or discovery request, provided certain conditions are met, including that:
• the requesting party must give the Plan satisfactory assurances a good faith attempt has been made to provide you with
written Notice, and
• the Notice provided enough information about the proceeding to permit you to raise an objection, and
• no objections were raised or were resolved in favor of disclosure by the court or tribunal.
7. When required for law enforcement health purposes (for example, to report certain types of wounds).
8. For law enforcement purposes if the law enforcement official represents that the information is not intended to be used
against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to
obtain the individual’s agreement and the Plan in its best judgment determines that disclosure is in the best interest of the
individual. Law enforcement purposes include:
• identifying or locating a suspect, fugitive, material witness or missing person, and
• disclosing information about an individual who is or is suspected to be a victim of a crime.
9. When required to be given to a coroner or medical examiner to identify a deceased person, determine a cause of death
or other authorized duties. When required to be given to funeral directors to carry out their duties with respect to the
decedent; for use and disclosures for cadaveric organ, eye or tissue donation purposes.
10. For research, subject to certain conditions.
11. When, consistent with applicable law and standards of ethical conduct, the Plan in good faith believes the use or disclosure
is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the
disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat.
12. When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs
established by law.
13. When required, for specialized government functions, to military authorities under certain circumstances, or to authorized
Federal officials for lawful intelligence, counterintelligence and other national security activities.
Any other Plan uses and disclosures not described in this Notice will be made only if you provide the Plan with written
authorization, subject to your right to revoke your authorization, and information used and disclosed will be made in compliance
with the minimum necessary standards of the regulation.
20 MPS 2020-2021 Enrollment GuideYou can also read
