TABLE OF CONTENTS WELCOME TO ARCHES HEALTH PLAN. Welcome to Arches Health Plan Member Tools MyArches.org Member Website

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1 MEMBER GUIDE

2 TABLE OF CONTENTS Welcome to Arches Health Plan Member Tools MyArches.org Member Website Understand Your Benefits Access to Providers Urgent and Emergency Care Traveling Outside Utah Disease and Case Management Mental and Behavioral Health Pharmacy Benefits How We re Different Member Governed, A True Nonprofit Health Plan Bending the Cost Curve, Improving Care Self Care Preventive Screenings Arches Above & Beyond: Discounts We re Here to Help Qualifying Life Event Changes Authorization Determining your Financial Responsibility How to Submit a Claim for Covered Services Appeals Utilization Management Evaluating New Technology Quality Improvement Program Member Rights and Responsibilities Glossary of Key Terms Privacy Policy WELCOME TO ARCHES HEALTH PLAN Valued Arches Health Plan Member, Thank you for choosing Arches Health Plan. I am pleased to welcome you as a member of Utah s only health CO-OP or Consumer Operated and Oriented Plan. Through innovation in care coordination, cost transparency, and exciting new tools, Arches Health Plan is able to change the way you may experience health care. At Arches Health Plan, we are dedicated to making health insurance better for you, and your family. Please review this guide, and the rest of the documents in your welcome kit. Collectively they will help you get the most out of your membership and help you see how Life is Better Under the Arch. Linn Baker Chief Executive Officer New Member To-Do List: Read through this Member Guide Note which preventive screenings you may have missed Review your Summary of Benefits and Coverage File all of your materials in a safe place Sign up for your member account at MyArches.org Take an online health appraisal on MyArches.org Read any educational material generated by your health appraisal Review your health appraisal results with your primary care practitioner If you don t have a primary care practitioner, you can find one at MyArches.org Make an appointment if it s been 1-3 years since your last physical exam Explore Well Being Solutions on MyArches.org 1

3 Member Tools Arches Health Plan provides these materials in hard copy: This Member Guide, including: - Member Rights and Responsibilities - Notice of Privacy Practices Summary of Benefits and Coverage (SBC) Your Member ID Card (carry it with you always) MyArches.org: The Member Website As an Arches Health Plan Member you are provided with practical tools to manage your benefits, engage in healthy behaviors, and make payments through MyArches.org. To explore the tools available to you as a member of Arches Health Plan, visit MyArches.org today. It is safe, secure and of course it s free. MyArches.org materials are available in hard copy if you would prefer. Contact Arches Health Plan Customer Service to request a copy (details on back cover). MY ONLINE SERVICES Arches Health Plan has contracted with Coventry Health Care to provide some of your member tools and services through My Online Services. Services include a provider search, health risk assessment, wellness education based on your health appraisal results, claims information, and pharmacy tools. You can access My Online Services through MyArches.org. To register for My Online Services you will need your Member ID number. If you have not yet received your member ID number please call the customer service number on the back of this guide and speak with one of our representatives. WELL BEING SOLUTIONS Well Being Solutions are digital coaching tools that help you take steps to improve your health through consultation, making a plan, suggesting appropriate tools and following up. Visit Well Being Solutions to explore programs about weight management, physical activity, stress management, improved nutrition, tobacco cessation and more. HEALTH APPRAISAL Think of a Health Appraisal as a snapshot of you current health. How healthy are you compared to people your age? What is your first step to getting healthier? Find out by taking the Health Appraisal through My Online Services. Once you have completed your Health Appraisal, consult with your primary care practitioner so he or she can guide you toward better health. The Health Appraisal generally takes minutes. Don t worry, you can always start the process and finish later. HEALTH INFORMATION LIBRARY Through My Online Services, Arches Health Plan members have access to a vast library of information and tools to help you make better health decisions (HealthWise ). Look here for information about your conditions, medication, support groups, and interactive health decision tools. 3

4 UNDERSTAND YOUR BENEFITS Access to Providers Arches Health Plan is committed to facilitating a better way for practitioners and members to interact. We want to reward practitioners for coordinating your care if you get sick or for helping you stay well. We are developing patient management tools for our preferred practitioners to assist them in their efforts. Over 5,000 Utah providers participate in the Arches Health Plan network. You may obtain information about practitioners who participate in our network, primary care services (including points of access), specialty care, behavioral health care services and hospital services by visiting our provider search on MyArches.org. If you don t have a primary care practitioner, please use this provider search to select one. For hospital services on the Wasatch Front, Arches Health Plan contracts with IASIS, MountainStar, University of Utah (which includes Huntsman Cancer Institute), Primary Children s Medical Center and selected services at Utah Valley Regional Medical Center. In rural Utah we work with Intermountain Healthcare and other community hospitals including St. Mary s in Grand Junction, Colorado. For a complete list of the hospitals, providers and practitioners covered by Arches Health Plan, please visit our provider Urgent and Emergency Care If you need medical attention within 24 hours, but your problem is not life threatening, try calling your primary care practitioner first. If he or she can t see you, please visit our provider search on MyArches.org to find one of our participating urgent care clinics. For any medical emergency, call or go to the closest Traveling Outside Utah When traveling outside Utah, participating benefits will apply to any medically necessary urgent care facility visits. To limit your out-of-pocket expenses for any urgent care facility visits outside of Utah, you can use the Coventry National Network. Visit our provider search on MyArches.org for a list of participating providers and facilities in the Coventry National Network. For any medical Disease and Case Management Whether you have an urgent or ongoing condition, our case managers offer oneon-one support and help coordinate your care. Case Management is completely voluntary and confidential. You may opt in or out of the program at any time. For more information, please call the customer service number on the back of this guide and ask for case management. Mental and Behavioral Health Arches Health Plan uses MHNet for mental health and substance abuse services. Call toll free , 24 hours a day, 7 days a week. For emergencies, call Pharmacy Benefits Arches Health Plan pharmacy benefits allow you to obtain prescription medications from over 76,000 retail pharmacies nationwide. The pharmacy benefit is administered by Express Scripts (ESI) and Coventry Health Care of Utah. To find a pharmacy near you visit MyArches.org. Arches Health Plan uses a tiered drug list to save you and the CO-OP money. Tier 0 - No Copay Tier 1 - Lowest Copay Tier 2 - Higher Copay Tier 3 - Highest Out-of-Pocket Expense For a full list of covered medications please visit MyArches.org. For all preferred medications (tier 1 and 2), you may use Arches Health Plan prescription mail services. For most plans, you can get a 90-day supply of your medication for 2 months of co-pay. For details call customer service (see back cover) and speak with one of our representatives. 5

5 HOW WE RE DIFFERENT Member Governed, a True Nonprofit Health Plan Unlike typical insurance companies, we don t answer to shareholders or a traditionally distant board of directors. Arches Health Plan is governed by its members, much like a credit union. A majority of the elected board members will be general board members elected from and by the membership of Arches Health Plan. Members will also elect four special board members with required expertise for a health insurance company: a Chairman, and individuals with expertise in health care and insurance such as actuaries, practitioners, and financial officers. Bending the Cost Curve, Improving Care The founders of Arches Health Plan believe that the current health care system is unsustainable. By working together as a community of CO-OP members to stay healthy and manage our resources wisely, we may find savings and improve services for our members and providers. By law, any profit must go towards our members benefit. Arches Health Plan is committed to becoming The Way Health Care Gets Better. 7

6 SELF CARE & WELLNESS TOOLS Preventive Screenings: What are my preventive care benefits? You can help yourself and your family by keeping up to date on preventive screenings. As of January 1, 2014, all age-appropriate screenings are covered without any co-pay or deductible. No matter what type of health plan you have chosen, Arches Health Plan encourages you to find an in-network primary care practitioner using our provider search on MyArches.org. Your primary care practitioner can help you make the best use of preventive screenings and immunizations. Recommendations vary by age and gender, as shown in the tables below. Here is a sample of covered preventive services (please work with your primary care practitioner to determine exactly what you need). ADULT (Men & Women) Physical Exam: once a year, unless otherwise directed Immunization/Vaccines: for adult doses, recommended ages, and recommended populations vary (see table on page 7) Sexually Transmitted Infection (STI): Screening and counseling for adults at high risk Colorectal Cancer Screening: Colonoscopy for adults over 50 or younger depending on family history of colon cancer Diet Counseling: for adults at higher risk for chronic disease For a complete detailed list, please visit healthcare.gov WOMEN (In addition to above) Breast Cancer Mammography Screening: Every 1 to 2 years for women over 40 Breastfeeding Comprehensive Support and Counseling: provided by trained providers; and access to breastfeeding supplies, for pregnant and nursing women Cervical Cancer Screening: Pap smear for women 21 years of age or older Domestic and Interpersonal Violence Screening and Counseling: For all women Contraception: visit the link below For a complete detailed list, please visit healthcare.gov CHILD IMMUNIZATION & VACCINES Vaccine Birth 1 m 2 m 4 m 6 m 12 m 15 m 18 m 24 m 3 yrs 4-6 yrs DTaP t t t t t Hepatitis A t 2 dose series Hepatitis B t t t Haemophilus Influenzae type b (Hib) t t t t Influenza (Flu) t yearly MMR (MMRV) Combined measles, mumps, rubella and varicella vaccine (MMRV) is preferred t t Varicella (Chickenpox) for children 12 months through 12 years of age instead of Individual vaccines. t t Pneumococcal (PCV) t t t t Polio Virus (IPV) t t t t Rotavirus t t t Note: If your child misses a shot, you don t need to start over, just go back to your child s doctor for the next shot. Talk to your child s doctor if you have questions about vaccines. ADULT IMMUNIZATION & VACCINES Haemophilus Influenzae type b (Hib) Inactivated Polio Vaccine (IPV) 1 dose Booster at 16 1 or more doses for adults with certain risks, talk to your doctor For those with certain high risks, talk to your doctor, 2 doses for adults if doctor recommended Catch up 3 doses for those with certain high risks, talk to your doctor 1 or 3 doses for adults with certain risks, talk to your doctor Source: CDC.gov/vaccines Vaccine 7-10 yrs yrs yrs yrs yrs yrs yrs yrs 65+ yrs Influenza (Flu) Get a flu vaccine every year Tetanus, Diphtheria, Pertussis (Td/Tdap) Catch up 1 dose Catch up Get a Tdap vaccine once, then a Td booster vaccine every 10 years Varicella (Chickenpox) 2 doses if not received as a child HPV (Women) 3 doses 3 doses if not received as pre-teen Adults with risks, talk to your doctor HPV (Men) 3 doses 3 doses if not received as pre-teen Adults with risks, talk to your doctor Zoster (Shingles) 1 dose Measles, Mumps, Rubella (MMR) 1-2 doses if not received as a child Pneumococcal (PCV13) 1 dose for those with certain medical condititions, talk to your doctor Pneumococcal (PPSV23) 1-2 doses for adults with risk, talk to your doctor 1 dose Meningococcal Conjugate (MCV4) Hepatitis A (Hep A) Hepatitis B (Hep B) Catch up Set doses Catch up / if not received as a child Doses for those with certain medical risks / per doctor recommendation Highly recommended CHILDREN (Birth through 17 years old) Well Child Physical Exam: For all children throughout development. Age appropriate screenings Immunization vaccines: For children from birth to age 18. Doses, recommended ages, and recommended sub-populations vary Autism Screening: For children at 18 and 24 months Behavioral Assessments: For all children Vision Screening: For all children For a complete detailed list, please visit healthcare.gov 9

7 Above & Beyond: Health Discounts for Members Arches Above & Beyond provides everyday savings on healthy products and services to Arches Health Plan members. Above & Beyond is a value-added program, completely free and separate from your Arches Health Plan medical benefits. It is a non-covered benefit, so you pay directly for the services you receive. Many of the items are coupons and simple downloads; some are promotions that will require you to mention being an Arches Health Plan member upon making your appointment and present your Arches Health Plan ID Card at the time of services. Free of charge, exclusive to members, Above & Beyond is your gateway to healthy savings on everyday items. For more information, visit ArchesAboveandBeyond.org, and simply click on the items that interest you. Be sure to check the website often, as additional values continue to become available. ABOVE & BEYOND SAMPLE OFFERINGS Acupuncture & massage therapy Dental discounts Eye care products & services Fitness & relaxation downloads Gym memberships, home fitness Nutrition products Hearing aids & exams LASIK surgery Weight management And more! 11

8 WE RE HERE TO HELP This guide addresses questions most likely to come up for our members. For more detailed information about your plan and how it works, please see your Summary of Benefits and Coverage. For any other questions or issues, please call member services (see back cover for details) or visit the Frequently Asked Questions section of MyArches.org. Qualifying Life Event Changes If you have a life event such as marriage, divorce, birth, adoption, moving or gaining citizenship and you would like to adjust your coverage, please call the customer service number on the back of this guide. Authorization In some instances, you may need to receive an authorization for specific services, as applicable, to be covered. You may work with your primary care provider to obtain authorization. If you cannot work with your primary care provider or if you have any other questions about authorizations, you may call and speak to one of our representatives. Determining your Financial Responsibility To determine your benefit and financial responsibility for a specific service or treatment from a specified provider or institution, you may call the customer service number on the back of this guide and speak to one of our representatives. How to Submit a Claim for Covered Services When you receive services from a non-participating provider due to emergency care services, you should file a claim with us only if the non-participating provider does not file a claim for you. Medical claims must be filed within 12 months of the date of service, pharmacy claims must be filed within 3 months of the date of service. For questions on how to submit a claim for covered services, if applicable, please use the customer service number on the back of this guide and speak with one of our representatives. Appeals You can appeal a decision that adversely affects coverage, benefits or your relationship with Arches Health Plan. If you have a concern or a request for reconsideration regarding an adverse benefit determination, you must follow the Grievances and Appeals internal review process detailed in your Certificate of Coverage which can be found on MyArches.org. Any questions or requests for information that you may have about the appeals or the Grievances and Appeals internal review process can be mailed to the Appeals address on the back of this guide or you may call the customer service number that is also located on the back of this guide and speak with one of our representatives. Any request for reconsideration of an adverse benefit determination that is based on medical judgment will be reviewed by a committee that includes a physician. If necessary, the committee will consult a health care professional, or professionals, who have appropriate training and experience in the field of medicine related to the subject of the adverse benefit determination. Utilization Management As part of Arches Health Plan s commitment to high-quality care, member satisfaction and exceptional service, our utilization management (UM) program helps ensure that our members receive medically necessary health care services in the most cost-effective setting according to their benefit package. Working with the member and the physician, we evaluate services for medical appropriateness, timeliness and cost. Our decisions are based exclusively on appropriateness of care and service, and the existence of coverage. We do not compensate or reward practitioners, employees or other individuals for denying coverage or care. In addition, Arches Health Plan does not use financial incentives to reward or encourage decisions that result in underutilization or inappropriate restrictions of care for our members. If you have questions about utilization management issues you may call the customer service number on the back of this guide and speak to one of our representatives. 13

9 Evaluating New Technology To ensure that we offer you the tools you need to manage your health, Arches Health Plan evaluates new technology for inclusion as a covered benefit. When new technology is either developed or purchased, a select committee reviews specific requirements, which are not limited to, functionality, scalability, compatibility, security, accessibility, cost and medical necessity. Quality Improvement Program Arches Health Plan is committed to providing the highest quality of care to our members while incorporating market based incentives to drive improvements in quality more broadly in the community. The mission of Arches, as a Consumer Operated and Oriented (CO-OP) Health Plan, is to optimize health outcomes for our members by making our plans affordable, enhancing access to care, and ensuring sustainability. Arches is a non-profit CO-OP plan that has served Utahns since January, Created by loans granted in the Affordable Care Act, CO-OP plans give consumers and small businesses additional options for health insurance while complying with all essential benefits and regulations defined by state and federal law. The Arches Health Plan Quality Improvement Program is integrated within all health plan operations and provides a mechanism for the coordination of quality improvement, medical and behavioral health management, member services and all essential plan functions that contribute to the quality of member care and services. The Quality Improvement Program is reflective of the local health care delivery system and provides for a systematic approach to continuous improvement, encompassing the quality of evaluation and improvement activities across the continuum of health care services that impact members and providers. As Arches gains experience with its provider network and membership base, the Quality Improvement Program will evolve with the intent of rewarding quality through market-based incentives for both CO-OP members and Arches providers and practitioners. Member Rights and Responsibilities As a member of Arches Health Plan, you have certain rights and responsibilities. These are provided to help you make the most of your benefits and to help you get the best possible care when you need it. AS A MEMBER OF ARCHES, YOU HAVE THE RIGHT TO... Receive information about Arches Health Plan, our services, our practitioners and providers and member rights and responsibilities. Be treated with respect and recognition of your dignity and your right to privacy. Participate with practitioners in making decisions about your health care. A candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage. Voice complaints or appeals about Arches Health Plan or the care it provides. Make recommendations regarding your Arches Health Plan member rights and responsibilities. Secure storage of your personal health information (PHI) and any personal financial information given to Arches Health Plan. Confidentiality of all medical and financial records in accordance with state and federal law. AS A MEMBER OF ARCHES, YOU HAVE THE RESPONSIBILITY TO... Supply information (to the extent possible) that Arches Health Plan and its practitioners and providers need in order to provide care. Follow plans and instructions for care that you have agreed to with your practitioners. Understand your health problems and participate in developing mutually agreed-upon treatment goals, to the degree possible. 15

10 Glossary of Key Terms Arches Health Plan respects that many of our members may be new to insurance or unfamiliar with insurance terminology. The following are terms worth learning. Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance or negotiated rate. If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Appeal A request for your health insurer or plan to review a decision or a grievance again. Balance Billing When a provider bills you for the difference between the provider s charge and the allowed amount. For example, if the provider s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Claim A request for payment that you or your provider submits to your insurer when you get items or services you think are covered. Copayment (Copay) A fixed amount you pay for a given service (like a primary care visit) listed on your Arches Health Plan member ID card. You pay the provider directly at the point of service. Coinsurance A percentage of the allowed amount that you must pay for covered services to a provider or facility. Deductible A dollar amount listed on your ID card that you must pay each year for covered services before Arches Health Plan makes any payment. Some benefits may be subject to separate deductibles. For example, for many Arches health plans there is no deductible for accidents. Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Excess Charges Charges from providers that exceed allowed amounts for that service. These charges and excess charges from the use of nonparticipating providers are your responsibility. They do not apply to your out-of-pocket maximum. Some plans do not have out of network benefits. Please check your member materials to verify. Excluded Services Health care services that your health insurance or plan doesn t pay for or cover. Grievance A complaint that you communicate to your health insurer or plan. Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn t walking or talking at the expected age. These services may include physical and occupational therapy, speechlanguage pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. Home Health Care Health care services a person receives at home. Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Hospital Outpatient Care Care in a hospital that usually doesn t require an overnight stay. In-network Co-insurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. Insurance CO-OP It is a Consumer Operated and Oriented Plan. It is a nonprofit entity in which the same people who govern the company are insured by the company. Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Non-Preferred Provider A provider who doesn t have a contract with your health insurer or plan to provide services to you. You ll pay more to see a nonpreferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn t cover. Some health insurance or plans don t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Practitioner A licensed or certified professional who provides medical or behavioral healthcare services. Physician Services Health care services a licensed medical physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) provides or coordinates. Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn t a promise your health insurance or plan will cover the cost. Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also participating providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more. Premium The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications. Prescription Drugs Drugs and medications that by law require a prescription. Primary Care Physician (PCP) A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. This is a physician specialized in the care of general medical conditions. They serve as a resource for first contact for a person with an undiagnosed non emergent health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. They focus on non-emergent acute and the long term management of chronic health conditions serving as the central organizer of information and coordination for patients. Consist of Pediatrics, Family Medicine, General Medicine, Internal Medicine and often Obstetrics/Gynecology. Provider An institution or organization that provides services, such as a hospital, residential treatment center, home health agency or rehabilitation facility. A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law. Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions. Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speechlanguage pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. Specialist Physician Physicians who have completed advanced education and clinical training in a specific area of medicine (their specialty area). Examples of medical specialists include the following: Orthopedics, Endocrinology, Dermatology, Cardiology and others. A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. 17

11 Privacy Policy This policy describes how information about you may be used and disclosed and how you access this information. Please review it. OUR COMMITMENT We understand your privacy is important to you. The law defines protected health information or PHI, as individually identifiable health information on the physical or mental condition of an individual which is transmitted or maintained in any form or medium. This includes facts of service and payment for health care service for individuals. This personal information is covered by federal and state privacy rules. As such, the use and disclosure of your information is regulated and enforced. As part of providing our services to you, you understand that we will obtain personal information about you. We treat the personal information we obtain from you or other sources, including business associates, and agents, in the course of providing you with our products and services seriously. Therefore, this privacy notice provides awareness on measures we take to protect your privacy. It also describes information we collect and how we use this information to conduct our business. We do not sell our customer lists or individual customer information. You agree that we may collect, use, and share information as described below. YOUR HEALTH INFORMATION RIGHTS You may: Review and get a paper copy of your policy or claims records as allowed by law, usually within 30 days of your request (you can also ask us to provide a copy in electronic form, and we will do that if we can readily produce it); Request and be provided a paper copy of our current Notice of Privacy Practices, or receive an electronic copy by if you have agreed to receive an electronic copy; Ask us to contact you at a specific address or phone number if contacting you at your current address or phone number could endanger you; Request and receive an accounting, as specified by law, of certain situations when your information was shared without your consent; Receive a notice if Arches or one of its Business Associates causes a breach of your unsecured information; Report a privacy concern and be assured that Arches will investigate your concern thoroughly, supporting you appropriately, and not retaliate against you in any way (in fact, Arches will provide you with information on how to report any privacy concerns to the Arches Privacy Coordinator or the Office for Civil Rights, U.S. Department of Health and Human Services); and Request in writing other restrictions on the use of your health information or amendments to your health information if you think it is wrong, though Arches may not always be able to grant those requests. WHAT WE COLLECT Information about you may come from the following: Information on applications or in communications with us such as your name, address, phone numbers, medical information, employment information, date of birth and social security number; Information about your transactions with us such as your account balance, fees, payments, and the identity of persons to whom you make payments including health care providers ; Information from public sources such as government records; Information that we obtain from you on our website, including digital signature; We have developed policies and procedures to keep your personal information confidential and secure. We restrict access to those employees and other persons who must use that information to provide services on our behalf. We maintain physical, electronic and procedural safeguards, in compliance with applicable laws, regulations and industry standards, to protect the confidentiality of the personal information we obtain. Instructions for you to communicate in a confidential and secure manner with us is located on our website at archeshealth.org. HOW YOUR HEALTH INFORMATION IS USED Common Uses of Health Information. As we provide health insurance benefits, we will gather some of your health information. The law allows us to use or share this health information for the following purposes: To receive payment of health coverage premiums and to determine and fulfill Arches' responsibility to provide you benefits. For example, to make coverage determinations, administer claims, and coordinate benefits with other coverage you may have; To support health care providers in providing treatment; To share in limited circumstances health information with your plan sponsor. However, Arches will only do so if the plan sponsor specifically requests health information for the administration of your health plan and agrees in writing not to use your health information for employment-related actions or decisions; To identify health-related services that may be beneficial to your health and then contact you about these services; To improve our services to you by allowing companies with whom we contract, called "business associates," to perform certain specialized work for us. The law requires these business associates to protect your health information and obey the same privacy laws that we do; To perform a very limited, specific type of health related research, where the researcher keeps any patientidentifiable information safe and confidential. Arches reviews every research request to make sure your privacy is appropriately protected before sharing any health information; To law enforcement, but only as authorized by law, i.e. to investigate a crime against Arches or any of its members; To improve the overall Arches system as well as to help better manage your care. REQUIRED USES OF HEALTH INFORMATION The law sometimes requires us to share information for specific purposes, including the following: To the Department of Health to report communicable diseases, traumatic injuries, or birth defects, or for vital statistics, such as a baby's birth To a funeral director or an organ-donation agency when a patient dies, or to a medical examiner when appropriate to investigate a suspicious death; To state authorities to report child or elderly abuse; To law enforcement; To a correctional institution, if a member is an inmate, to ensure the correctional institution's safety; To the Secret Service or NSA to protect, for example, the country or the President; To a medical device's manufacturer, as required by the FDA, to monitor the safety of a medical device; To court officers, as required by law, in response to a court order or a valid subpoena; To governmental authorities to prevent serious threats to the public's health or safety; To governmental agencies and other affected parties, to report a breach of health-information privacy; To a worker's compensation program if a person is injured at work and claims benefits under that program. USES ACCORDING TO YOUR REQUESTS Your preferences matter. If you let us know how you want us to disclose your information in the following situation, we will follow your directions. You decide if you want us to share any health or payment information related to your care with your family members or friends. Please let our Arches employees know what you want us to share. If you can't tell us what health or payment information you want us to share, we may use our professional judgment to decide what to share with your family or friends for them to be able to help you. USES WITH YOUR AUTHORIZATION Any sharing of your health information, other than as explained above, requires your written authorization. For example, we will not use your health information unless you authorize us in writing to: share any of your health information with marketing companies sell any of your health information. You can change your mind at any time about sharing your health information. Simply notify Arches in writing. Please understand that we may not be able to get back health information that was shared before you changed your mind. SPECIAL LEGAL PROTECTIONS FOR CERTAIN HEALTH INFORMATION Arches complies with federal laws that require extra protection for your health information if you receive treatment in an addiction treatment program, or from a psychotherapist who keeps notes on your therapy that are kept outside of your regular medical record. Arches is prohibited from using or disclosing genetic information for underwriting purposes. IF YOU STILL HAVE QUESTIONS Arches Privacy Coordinator can help you with any questions you may have about the privacy of your health information. He can also address any privacy concerns you may have about your health information and can help you fill out any forms that are needed to exercise your privacy rights. This privacy notice became effective on November 1, We may change this privacy notice at any time, and we may use new ways to protect your health information. We always post our current privacy notice on our website at archeshealth.org You can also obtain a copy of this notice from any of Arches' staff by asking for a copy by visiting our website, or by calling Arches' Privacy Office at (801)

12 CONTACT US CUSTOMER SERVICE Individuals enrolled in the subsidized federal marketplace: :00 AM to 6:00 PM (MT) Monday through Friday Individuals enrolled outside of the marketplace or groups: :00 AM to 6:00 PM (MT) Monday through Friday Para obtener asistencia en Español, llame al All other languages call For TTY/TDD relay services, please call For Spanish TTY/TDD relay services, please call PHARMACY HELP DESK Administered by Coventry / Express Scripts: :00 AM to 8:00 PM (MT) Monday through Friday COMPANY WEBSITE ArchesHealth.org MEMBER WEBSITE MyArches.org APPEALS Arches Health Plan C/O Coventry Health Care of Utah Appeals Department S. Jordan Gateway #400 South Jordan, UT Expedited Appeals, if needed please call: MENTAL HEALTH & SUBSTANCE ABUSE For information regarding providers, prior authorization, or immediate access to care: Non-Emergent 8:00 AM to 5:00 PM (MT) Monday through Friday Emergency 24 hours / 7 days (call in the event of an emergency) If you would like to voice a complaint, you may call the customer service phone number above and speak with one of our representatives. If you would prefer to receive materials and communications from Arches Health Plan in hard copy, please send an to: ArchesCustService@cvty.com or call the customer service number listed above and speak with one of our representatives. Si prefiere recibir estos materiales y otras comunicaciones de Arches imprimidos en una copia de papel, por favor envíe un correo electrónico a ArchesCustService@cvty.com o llame al número de servicio al cliente anterior. MKT100_V4 (12/14)