How To Understand The Health Care Plan

Transcription

1 TEXAS CHILDREN'S HOSPITAL EMPLOYEE MEDICAL CLINIC AND EMPLOYEE ASSISTANCE PROGRAM (Amended and Restated Effective as of January 1, 2012) Every effort has been made to provide you with clear, accurate, understandable information about the Texas Children's Hospital Employee Medical Clinic and Employee Assistance Program. This is a description of the current programs. While Texas Children's Hospital intends to continue the benefits described in this Summary, it reserves the right to end, suspend or amend any or all of the programs at any time, in whole or in part. Should this happen, you will be notified.

2 TABLE OF CONTENTS INTRODUCTION...1 GENERAL INFORMATION ABOUT THE PLAN...2 Page Q:1 -- What is the Plan?...2 Q:2 -- Am I eligible to participate in the Plan?...2 Q:3 -- Are my family members eligible for coverage under either of the Component Benefit Programs?...2 Q:4 -- Do I have any financial obligations under the Plan?...2 Q:5 -- Do I need to enroll in the Plan?...2 Q:6 -- How do I make a claim for benefits under a Component Benefit Program?...2 Q:7 -- What obligations do I have in the event I receive more benefits than I am entitled under a Component Benefit Plan?...3 Q:8 -- When will my coverage under the Plan and Component Benefit Programs terminate?3 Q:9 -- What happens to my coverage under the Plan and Component Benefit Programs if I have a leave of absence?...4 Q:10 -- Are there any laws that provide me or my family special rights under the Plan or Component Benefit Programs?...4 Q:11 -- May the Plan be amended or terminated?...5 Q:12 -- Does the Plan or any of the Component Benefit Programs constitute a contract of employment?...5 Q:13 -- How is the Plan administered?...5 EMPLOYEE MEDICAL CLINIC...6 Q:14 -- What is the purpose of the Clinic?...6 Q:15 -- When would coverage begin?...6 Q:16 -- What benefits are provided by the Clinic?...7 Q:17 -- Is there any cost associated with my access to or receipt of services from the Clinic?.7 Q:18 -- Are services provided at the Clinic provided on a confidential basis?...7

3 EMPLOYEE ASSISTANCE PROGRAM...7 Q:19 -- What is the purpose of the EAP?...7 Q:20 -- What are the benefits under the EAP?...7 Q:21 -- Is there any cost associated with my participation in the EAP?...8 Q:22 -- Are services under the EAP provided on a confidential basis?...8 HIPAA PRIVACY AND SECURITY RULES...8 Q:23 -- How does HIPAA apply to the various components of the Plan?...10 Q:24 -- When can PHI be used and disclosed by the EAP?...10 Q:25 -- What is the certification required by the Employer?...10 Q:26 -- If PHI is disclosed to an Employer, which employees will have access to PHI?...12 Q:27 -- Who is the privacy officer of the EAP? Who is the security officer of the EAP?...12 Q:28 -- What happens if there is a violation of privacy or security rules?...12 EXHIBIT A DEFINING THE TERM "EMPLOYER" EXHIBIT B/PART 1 ERISA PLAN INFORMATION EXHIBIT B/PART 2 STATEMENT OF ERISA RIGHTS EXHIBIT C - CLAIMS AND APPEALS PROCEDURES EXHIBIT D/PART 1 CONTINUATION OF COVERAGE UNDER COBRA EXHIBIT D/PART 2 COBRA NOTICE PROCEDURES EXHIBIT E/PART 1 HIPAA PRIVACY NOTICE EXHIBIT E/PART 2 DESIGNATION OF EMPLOYEES WITH ACCESS TO PHI EXHIBIT F OTHER GENERAL INFORMATION EXHIBIT G OTHER APPLICABLE MANDATES

4 TEXAS CHILDREN'S HOSPITAL EMPLOYEE MEDICAL CLINIC AND EMPLOYEE ASSISTANCE PROGRAM PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION INTRODUCTION Texas Children's Hospital (the "Hospital") previously established the Texas Children's Hospital Employee Assistance Program (the "Plan") for the benefit of employees of the Hospital and certain participating employers set forth in EXHIBIT A (collectively with the Hospital, the "Employers"). The Plan is amended effective as of February 1, 2012 to add the Employee Medical Clinic. Accordingly, effective January 1, 2012, the Plan is renamed the Texas Children s Hospital Employee Medical Clinic and Employee Assistance Program and includes the following component benefit programs (collectively, the "Component Benefit Programs"): o Employee Medical Clinic (the "Clinic"), and o Employee Assistance Program (the "EAP"). This document, along with the attached EXHIBITS, the Annual Benefits and Wellness Guide and any other information incorporated by reference, shall constitute the plan document for the Plan and each Component Benefit Program. Notwithstanding the number and types of benefits incorporated under the Plan, and except to the extent otherwise provided herein to satisfy requirements under applicable law, the Plan is and shall be treated as, a single welfare benefit plan to the extent permitted under applicable law. For all purposes under the Plan, use of the term "Spouse" shall be defined in accordance with the Defense of Marriage Act. This document also constitutes the Summary Plan Description (this "Summary") for the Plan and each Component Benefit Program, to the extent required by applicable law and is intended to describe your rights under the Plan and the benefits provided under each Component Benefit Program. If the non-technical language contained herein conflicts with the technical language set forth in the Annual Benefits and Wellness Guide, then the technical language in such document shall prevail over the non-technical language of this Summary. If you have any questions about the Plan or any Component Benefit Program, you may contact the Plan Administrator directly. For contact information of the Plan Administrator of the Plan, as well as the administrator of any Component Benefit Program, refer to EXHIBIT B entitled "ERISA Plan Information." 1

5 Q:1 -- What is the Plan? GENERAL INFORMATION ABOUT THE PLAN The Plan is an overall program that is sponsored and maintained by the Hospital to provide benefits under the Component Benefit Programs to eligible employees and their eligible dependents. Q:2 -- Am I eligible to participate in the Plan? All employees are eligible to participate in the Plan and Component Benefit Programs, regardless whether he or she works full-time, part-time or per diem and regardless of whether he or she is a participant in the Texas Children s Hospital Select Plan. Q:3 -- Are my family members eligible for coverage under either of the Component Benefit Programs? Only employees are eligible to participate in the Clinic. An eligible employee s eligible dependents are eligible for coverage and benefits under the EAP. For these purposes, "eligible dependents" is defined as follows: As defined in accordance with the Defense of Marriage Act, your legal spouse who is of the opposite sex (your "Spouse"), unless you are legally separated; Your child, until he or she attains age 26; and Any individual for whom you are entitled to claim an exemption on your Federal income tax return ("tax dependent"). Q:4 -- Do I have any financial obligations under the Plan? There is no cost for accessing either the Clinic or the EAP. However, you may be charged fees at the time services or treatments are rendered. Q:5 -- Do I need to enroll in the Plan? No. All employees are automatically enrolled in the Clinic. Additionally, all employee and their eligible dependents are automatically enrolled in the EAP. An individual who is enrolled is referred to as a "Participant." Q:6 -- How do I make a claim for benefits under a Component Benefit Program? A claim for benefits under the Component Benefit Programs must be filed no later than twelve (12) months following the date on which the expense was incurred (or such earlier date as may be provided under the applicable Component Benefit Program) and must be filed in accordance with the applicable claims procedures. See EXHIBIT C for more details. You should refer to 2

6 the applicable provisions of this Summary for more details on earlier filing deadlines and the information that must be submitted with your claim. You are not entitled to pursue any legal or equitable remedy with respect to your claim for benefits until you have exhausted the claims procedures provided under the Plan. Furthermore, you may not pursue any claim for benefits more than three (3) years following the date on which you exhausted the claims procedures provided under the Plan. Q:7 -- What obligations do I have in the event I receive more benefits than I am entitled under a Component Benefit Plan? In the event a Component Benefit Program provides to you (or another person on your behalf) benefits in excess of that to which you are entitled under the terms of the applicable Component Benefit Program, the Plan Administrator (or its authorized delegate) may recover the value of such benefits directly from you. For example, if they were: made in error; due to a mistake in fact; or provided because you or your dependent misrepresented facts. If the Component Benefit Program fails to charge the correct amount for a service or treatment provided to you or your dependent, the Plan Administrator may require that the you pay the deficiency to the Component Benefit Program or, to the extent you fail to pay such deficiency to the Component Benefit Program, you may be referred for collection, your benefits under the applicable Component Benefit Program may be reduced, and you may be subject to disciplinary action, including termination of employment, by your Employer. Q:8 -- When will my coverage under the Plan and Component Benefit Programs terminate? You and/or your eligible dependents' coverage under the Plan and each Component Benefit Programs will generally terminate under the circumstances and on the dates described in this section. However, you may have the opportunity to temporarily continue coverage under COBRA (see EXHIBIT D), during an employer-approved leave of absence (see Q:9), (HR Policy 208, 214 and 214a) and during a military leave of absence (HR Policy 205)(see EXHIBIT G). Termination of Employment: If your employment terminates, voluntarily or involuntarily, (including your layoff or retirement), then your coverage under the Plan and each Component Benefit Program will generally terminate at 11:59 p.m. on the last day of the pay period that contains your last day worked, except as otherwise specifically provided in this Summary or in a written separation, layoff or other agreement. For these purposes, your employment or active work status will end as of the date you fail to return to work with your Employer (i) after your FMLA leave, (ii) within your reemployment 3

7 period following a USERRA leave, or (iii) following expiration of any other Employer-approved leave. Dependent Coverage under the EAP Fraudulent Activities: In addition to the above, your eligible dependents' coverage under the EAP will terminate on the earliest of: (i) the date your coverage terminates for any reason; or (ii) the last day of the pay period your eligible dependent ceases to satisfy the requirements for eligibility to participate (e.g. attainment of age 26). You must notify the Plan Administrator, in writing, within sixty (60) calendar days of the date a dependent Spouse is no longer eligible to participate in the Component Benefit Programs as a result of divorce, legal separation or death, or of the date a dependent child is no longer eligible to participate in the Component Benefit Programs, if you or your eligible dependents intend to elect COBRA continuation coverage under the Component Benefit Programs. (See EXHIBIT D/PART 2 for a description of COBRA notification procedures.) If you and/or your dependents permit any other person who is not a Participant to use any identification card issued by the Plan or a Component Benefit or otherwise fraudulently claim a benefit or falsify information with respect to a benefit claim, the Plan Administrator may give you written notice that coverage for you (and such other person) is rescinded or that you are no longer eligible for benefits under the Plan or a Component Benefit Program. If the Plan Administrator gives such written notice, then you (and your dependents, as applicable) will cease to be eligible for the benefits under the Plan and applicable Component Benefit Programs as of the date specified in such written notice, and no coverage will be provided to you and your dependents under the Plan or Component Benefit Programs after that date. Q:9 -- What happens to my coverage under the Plan and Component Benefit Programs if I have a leave of absence? Your participation in the Plan and Component Benefit Programs will automatically continue during any absence from work due to (i) an approved medical or family leave of absence which is covered under the Family and Medical Leave Act of 1993 ("FMLA"), (ii) a military leave of absence which is covered under the Uniformed Services Employment and Reemployment Rights Act of 1994 ("USERRA"), or (iii) any other employer-approved leave of absence (collectively referred to as "leave"). Q:10 -- Are there any laws that provide me or my family special rights under the Plan or Component Benefit Programs? Certain federal and state laws may apply to your eligibility for and participation in the Plan and Component Benefit Programs. See EXHIBIT G for more details. However, the laws may not 4

8 apply equally to all Component Benefit Programs. General Notice and the COBRA Notice Procedures. See also EXHIBIT D for the COBRA Q:11 -- May the Plan be amended or terminated? The Hospital reserves the right to amend, modify or terminate the Plan and any and all of the Component Benefit Programs at any time. The Benefits Committee shall also have the right to amend the Plan or any Component Benefit Program at any time, provided such amendment does not have a significant cost impact on the Employers or is required by law. By adopting the Plan, each Employer authorizes the Hospital (and the Benefits Committee) to amend the Plan on its behalf without requiring any further action by the Employer. The Hospital shall notify each Employer of any such amendment. Any amendment to the Component Benefit Programs shall be in writing pursuant to resolution of the Hospital or Plan Administrator, or its authorized delegate. Any amendment so adopted may be executed on behalf of the Hospital by any authorized officer of the Hospital, or such other individual who may be authorized under the resolution adopting such amendment. The Benefits Committee will notify you if there are any changes to any of the provisions of the Plan or any Component Benefits Programs. In the event the Plan or any Component Benefit Program is amended to remove or reduce a benefit or is completely terminated, you and your dependents (and any person claiming through you and your dependents) will have no further rights to coverage under the Plan or applicable Component Benefit Program(s) as of the effective date of such amendment or termination (or such later date required by applicable law), and the Employers obligations with respect to such coverage will thereupon cease. Notwithstanding the foregoing, you will be eligible for benefits under the Component Benefit Programs with respect to your coverage up to the effective date of the amendment or termination (or such later date as may be required by law). Q:12 -- Does the Plan or any of the Component Benefit Programs constitute a contract of employment? While the Hospital believes in the benefits, policies and procedures described in the Component Benefit Programs, the language in the programs is not intended to create, nor may it be construed to constitute, a contract of employment between an Employer and any of its employees. Each Employer retains all of its rights to discipline or discharge employees or to exercise its rights as to incidents of employment. You have the right to terminate your employment at any time for any reason, and the Employer has a similar right with regard to terminating your employment. Q:13 -- How is the Plan administered? The Benefits Committee (the "Plan Administrator") was appointed by the Board of Trustees of the Hospital to administer the Component Benefits Programs and be the "Named Fiduciary" to the extent required by law. All members of the Benefits Committee shall serve in accordance with the rules adopted by the Benefits Committee from time to time. The Plan Administrator (or its delegate) has full discretion and binding authority to administer the Plan; interpret the Plan; determine eligibility for and the amount of benefits; determine the status and rights of Participants, beneficiaries and other persons; make rulings; make regulations 5

9 and prescribe procedures for administering the Plan; gather needed information; prescribe forms; exercise all of the power and authority contemplated by the Employee Retirement Income Security Act of 1974 ("ERISA") and the Internal Revenue Code with respect to the Plan and each Component Benefit Program; employ or appoint persons to help or advise in any administrative functions; appoint trustees and other service providers; and generally do anything needed to operate, manage and administer the Plan. The Plan Administrator has full discretionary and binding authority and control over the Plan, including that contemplated by the U.S. Supreme Court's decision in Firestone Tire & Rubber Co. v. Bruch. The Plan Administrator also shall have the power to delegate its fiduciary duties under the Plan or any Component Benefit Program to officers or employees of the Employers and to other persons (including insurers or third party administrators). Any employee so designated as a delegate of the Plan Administrator shall serve without compensation other than their regular remuneration from the Employer. For a list of persons or entities who have been delegated authority or responsibility under the Plan and the Component Benefit Programs, refer to EXHIBIT B. Each Employer will indemnify and defend to the fullest extent permitted by law any delegated employee or officer against all liabilities, damages, costs and expenses (including attorneys' fees and amounts paid in settlement of any claims approved by the Hospital), occasioned by any act or omission to act in connection with the Plan or any Component Benefit Program, if such act or omission is in good faith. Each fiduciary of the Plan is solely responsible for its own improper acts or omissions. A fiduciary shall not be liable for a breach of fiduciary duty committed before it became, or after it stopped being, a fiduciary. Generally, no fiduciary has the duty to question whether any other fiduciary is fulfilling all of the responsibilities imposed upon the other fiduciary by law. However, a fiduciary may be liable for a breach of fiduciary responsibility of another plan fiduciary, to the extent provided in ERISA Section 405(a). Q:14 -- What is the purpose of the Clinic? EMPLOYEE MEDICAL CLINIC The Hospital encourages all of its employees to focus on their personal health. While most employees have a primary care physician on whom they rely to receive ongoing medical care, many employees either delay receiving such care, or neglect obtaining such care altogether, due to the inconvenience in obtaining such care. The purpose of the Clinic is to provide you with convenient access to medical care at any time. The Clinic may be staffed with physicians, physician assistants, nurses, and other support staff and your medical information will be completely confidential and subject to the same privacy protections as apply when you seek medical care from your regular medical care provider. Q:15 -- When would coverage begin? Your access to the Clinic is automatically effective as of the later of February 1, 2012 or your first day of employment with an Employer. 6

10 Q:16 -- What benefits are provided by the Clinic? The Clinic is intended to provide convenient access to the same medical services as would be provided by your primary care physician. For example, you may obtain your annual physical at the Clinic and can receive medical attention for regular illnesses, such as the flu or allergies. For a complete description of the services and treatments available at the Clinic, refer to the Annual Benefits and Wellness Guide. Q:17 -- Is there any cost associated with my access to or receipt of services from the Clinic? There is no charge to employees for access to medical services at the Clinic. However, you will be charged a fee for services or treatments rendered at the Clinic (other than for preventive care), in much the same manner as you pay when you go to your primary care physician or pharmacy. The amount of the fee will be in the amount set forth in the Annual Benefits and Wellness Guide. Generally, however, the amount of the fee charged at the Clinic is less than the copayment and/or coinsurance required to be paid for similar medical care under the Texas Children s Hospital Select Plan. Q:18 -- Are services provided at the Clinic provided on a confidential basis? The Clinic is a health care provider subject to the privacy and security requirements of the Health Insurance Portability and Privacy Act ("HIPAA"). All services rendered to employees at the Clinic will be held in strict confidence. No Employer will have access to any identifying data or information concerning who has used the Clinic or the services provided to such employees without written permission of the individual or as otherwise permitted by HIPAA. Q:19 -- What is the purpose of the EAP? EMPLOYEE ASSISTANCE PROGRAM The Hospital cares about the health and well-being of its employees and recognizes that a variety of personal problems can disrupt their personal and work lives. While many employees are able to resolve problems either on their own, or with the help of family and friends, sometimes employees need professional assistance and advice. The purpose of the EAP is to provide referrals to appropriate providers and other community agencies that can assess and treat for personal, emotional, behavioral, mental health, alcohol and other substance abuses and similar problems of Employees, their Spouses, and other eligible dependents. Employees may be referred to the EAP by an Employer or may seek assistance voluntarily. In either event, participation in the EAP is strictly voluntary and confidential. Q:20 -- What are the benefits under the EAP? The EAP refers Participants to direct counseling, therapy and, if applicable, intensive treatment by a counseling department maintained within the Hospital. In addition, the EAP provides onsite trainings and educational opportunities to provide individuals, departments and leaders with ongoing access to support and to better manage situations and circumstances that can cause 7

11 disruption. Some of the topics that are addressed by the EAP include, but are not limited to, work, personal stress, anger, emotional, behavioral, mental health, alcohol and other substance abuses and similar problems of employees. For a complete description of the services available under the EAP, refer to the Annual Benefits and Wellness Guide. Q:21 -- Is there any cost associated with my participation in the EAP? All referral services, trainings and educational opportunities are free. However, any costs for therapy or other services recommended by the EAP will be subject be the sole responsibility of the employee. Note, however, some services and treatments may be payable or reimbursable by a group health plan in which you participate, subject to applicable limitations prescribed therein. Q:22 -- Are services under the EAP provided on a confidential basis? All referral services rendered through the EAP to employees and family members will be held in strict confidence. No Employer will have access to any identifying data or information concerning who has used or is involved with the EAP, without written permission of the individual or as otherwise permitted by HIPAA. In addition, involvement in the EAP will not be a factor for consideration in the employee's performance evaluation. HIPAA PRIVACY AND SECURITY RULES The EAP is a group health plan under the Health Insurance Portability and Accountability Act of 1996, as amended ("HIPAA"). Accordingly, the EAP is required to comply with HIPAA s privacy and security requirements as prescribed under implementing regulations ("Regulations"). Note, however, that, although this section does not apply to the Clinic, similar obligations under HIPAA will apply to the Clinic in its capacity as a health care provider. HIPAA restricts the ability of the EAP to use and disclose certain health information known as "protected health information" ("PHI"). The EAP will comply with HIPAA requirements effective April 14, 2004 for the Privacy rules and April 20, 2006 for the Security rules. Throughout this section, capitalized terms shall have the meaning ascribed below, unless otherwise specified in HIPAA. Electronic protected health information ("EPHI") means PHI that is transmitted by or maintained in electronic media (e.g. memory devices in computers, removable/transportable digital memory medium, etc.). Genetic Information means, except as otherwise provided by applicable law, with respect to each Participant, (i) such Participant's genetic tests; (ii) the genetic tests of family members of such Participant; (iii) the manifestation of a disease or disorder in family members of such Participant and (iv) any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by the Participant or any family member of such Participant. The term "Genetic Information" includes 8

12 information about a Participant's or family member's fetus or embryo. The term "Genetic Information" does not include information about the sex or age of any individual. Health Care Operations means the support functions related to treatment and payment, such as quality assurance activities, case management, receiving and responding to patient complaints, physician reviews, compliance programs, audits, business planning, development, management, and administrative activities. Health Care Provider means a provider of medical or other services, or one that furnishes medical or health care services or supplies (as defined in Sections 1861(s) and (u) of the Social Security Act). Individually Identifiable Health Information means information that (i) is created or received by the EAP, (ii) relates to the past, present, or future physical or mental health or condition of a Participant (whether living or deceased); the provision of health care to a Participant; or the past, present, or future Payment for the provision of health care to a Participant, and (iii) either identifies the Participant or with respect to which there is a reasonable basis to believe the information can be used to identify the Participant. Payment means activities to obtain and provide reimbursement for the health care provided to an individual, including determinations of eligibility and coverage under the EAP, and other health care utilization review activities. Plan Administration Functions means administration functions performed by the Employer on behalf of the EAP hereunder, such as quality assurance, claims processing, auditing and monitoring, but does not include functions performed by the Employer in connection with any other benefit or benefit plan of the Employer or any employmentrelated functions. Protected Health Information ("PHI") means Individually Identifiable Health Information that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium, except to the extent otherwise provided under HIPAA. The term "PHI" includes Genetic Information. Summary Health Information means information that may be Individually Identifiable Health Information and that summarizes the claims history, claims expenses, or types of claims experienced by Participants in the EAP, but with respect to which the identifiers specified in the Regulations have been removed. Treatment means the provision, coordination, or management of health care and related services by one or more health care providers, including coordination of care by a Health Care Provider with a third party, consultations between health care providers and referrals to other health care providers. 9

13 Q:23 -- How does HIPAA apply to the various components of the Plan? Because the Plan is comprised of two Component Benefit Programs and only the EAP is a healthcare component subject to HIPAA, the Plan is considered a "hybrid entity" under HIPAA. In this case, the healthcare component of the Plan consists of the EAP. The non-healthcare component of the Plan consists of the Clinic. The Plan intends to comply with HIPAA with respect only to the healthcare component of the Plan and to ensure adequate separation between the healthcare component and the non-healthcare component as if such healthcare component and non-healthcare component were separate and distinct plans. In this regard and to the extent required by HIPAA, the Plan will ensure compliance with the safeguard requirements relating to hybrid entities as set forth in Section 45 CFR (a) of HIPAA and in the Plan's HIPAA Privacy Policies and Procedures. Q:24 -- When can PHI be used and disclosed by the EAP? The EAP can use or disclose PHI only in a manner consistent with HIPAA, which generally is for purposes of Payment, Treatment and Health Care Operations; for Treatment activities of a Health Care Provider; for the payment activities of another covered entity; for certain Health Care Operations of other covered entities that also have or have had a relationship with the subject individual; and for Health Care Operations of other entities that are part of an organized health care arrangement with the EAP. Notwithstanding the foregoing, the EAP may not use or disclose Genetic Information for underwriting purposes. In addition to using Protected Health Information for the purposes described above, Protected Health Information may be disclosed by the EAP to an Employer, and the Employer may use and disclose Protected Health Information, for Plan Administration Functions (subject to receipt of a certification by the Employers, as set forth below), for enrollment and disenrollment purposes, and for any other purposes consistent with an individual's authorization or as permitted by the Regulations. In addition, Summary Health Information may be disclosed by the EAP to an Employer and may be used and disclosed by the Employer for purposes of obtaining premium bids for health insurance coverage under the EAP or modifying, amending, or terminating the EAP. For additional disclosures permitted under HIPAA, refer to the HIPAA Privacy Notice attached as EXHIBIT E. Q:25 -- What is the certification required by the Employer? The EAP may disclose PHI to an Employer (including certain members of the Employer's workforce) only to perform Plan Administration Functions on behalf of the EAP if the EAP has received a certification by the Employers. In this regard, the Hospital, on behalf of all Employers, certifies to the EAP, on its behalf and on behalf of each other Employer, that each Employer will appropriately safeguard and limit the use and disclosure of PHI that it receives from the EAP in a manner consistent with HIPAA. Specifically, the Hospital, on behalf of itself and all other Employers, agrees to: use or further disclose PHI only as permitted by and consistent with the EAP and HIPAA; 10

14 ensure that any agents, including a subcontractor, to whom it provides PHI received from the EAP agree to the same restrictions and conditions that apply to the Employer with respect to such information; not use or disclose PHI for employment related actions and decisions or in connection with any other benefit or employee benefit plan; report to the EAP any use or disclosure of the PHI that is inconsistent with the uses or disclosures permitted by HIPAA of which it becomes aware; make available for review by a covered individual his PHI to the extent required by HIPAA; permit a covered individual to cause his PHI to be amended to the extent required by HIPAA; make available to a covered individual an accounting of disclosure of his PHI to the extent required by HIPAA; make internal practices, books, and records relating to PHI available to the Department of Health and Human Services for purposes of determining compliance as required by HIPAA; if feasible, return or destroy all PHI received from the EAP that the Employer still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and ensure adequate separation between the EAP and the Employers is established and maintained. In addition, the Hospital (on behalf of itself and all other Employers) hereby certifies and agrees that each Employer will, except when the only EPHI disclosed to the Employer (i) is disclosed pursuant to a Participant's authorization, (ii) is Summary Health Information disclosed for the purpose of obtaining premium bids or modifying, amending, or terminating the applicable the EAP, or (iii) is enrollment, disenrollment, or participation information: ensure that the adequate separation between the EAP and the Employers (described above) is supported by reasonable and appropriate security measures to the extent that the individuals described therein have access to EPHI; to the extent that a Employer creates, receives, maintains or transmits any EPHI on behalf of the EAP, it will implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the EPHI; 11

15 ensure that any agents (including subcontractors) to whom it provides EPHI agree to implement reasonable and appropriate security measures to protect the information; and report to the appointed Security Officer any security incident of which it becomes aware. Q:26 -- If PHI is disclosed to an Employer, which employees will have access to PHI? The Hospital will allow access to PHI received from the EAP only to those employees who have administrative and management functions relating to the EAP and who have been specifically designated by the Hospital as employees authorized to access PHI pursuant to the HIPAA Privacy and Security Policies and Procedures adopted and maintained by the Privacy Officer. Their access to PHI is limited to the minimum necessary information needed to perform Plan Administration Functions on behalf of the EAP. See EXHIBIT E/PART 2 for a complete listing of the designated employees who serve as members of the workforce with access to PHI or EPHI. No other persons shall have access to PHI. Q:27 -- Who is the privacy officer of the EAP? Who is the security officer of the EAP? The EAP has designated the General Counsel of the Hospital at 6621 Fannin Street, Houston, Texas as the Privacy Officer. (Please contact the Plan Administrator for the name and address of the security officer). The Privacy and Security Officers are the privacy and security fiduciaries responsible for the EAP's compliance with HIPAA. Compliance includes ensuring that appropriate administrative, physical and technical procedures and safeguards are in place to protect PHI and to reasonably and appropriately protect the integrity, confidentiality and availability of any EPHI that an Employer creates, receives, maintains or transmits on behalf of the EAP. This also includes ensuring that employees who have access to PHI are trained in and appropriately handle PHI and EPHI in accordance with HIPAA, and understand the sanctions for HIPAA violations. Q:28 -- What happens if there is a violation of privacy or security rules? If an Employer becomes aware of violations of HIPAA, it shall arrange for the HIPAA Privacy or Security Officer appointed by the Hospital to consult with the person who has violated the privacy or security rules with respect to his or her obligations under HIPAA. An employee who violates HIPAA may be subject to discipline up to and including discharge. 12

16 IN WITNESS WHEREOF, the Hospital has adopted the Plan and this Summary as of the date indicated below. TEXAS CHILDREN'S HOSPITAL Dated: By: Its: 13

17 EXHIBIT A TEXAS CHILDREN'S HOSPITAL EMPLOYEE MEDICAL CLINIC AND EMPLOYEE ASSISTANCE PROGRAM Defining the Term "Employer" The Benefits Committee may designate any affiliated entity or organization eligible by law to participate in the Plan as an Employer. Such designation shall be in writing, shall specify the effective date of such participation, and shall be delivered to the Hospital and the Employer. Upon its provision of any information to the Benefits Committee required by the terms of, or otherwise submitted with respect to, the Plan, each Employer shall be conclusively presumed to have consented to such designation and to have adopted the Plan, and to have agreed to be bound by the terms of the Plan (including, without limitation, the terms of each Component Benefit Program) and any and all amendments thereto. Transfer of employment among the Hospital and other Employers shall not be considered a termination of employment hereunder. By appropriate action of its Board of Directors or noncorporate counterpart, any Employer (other than the Hospital) may terminate its participation in the Plan or any Component Benefit Program by giving written notice of intent to withdraw to the Benefits Committee and the Hospital at least ninety days prior to the proposed date of withdrawal, unless the Benefits Committee and the Hospital agree to waive all or part of such ninety-day notice. Moreover, the Benefits Committee in its discretion may terminate an Employer's participation in the Plan or any Component Benefit Program at any time by giving written notice of such termination to the Employer and the Hospital. For purposes of the Plan and this Summary, as of January 1, 2012 the term "Employer" includes only the following entities, which are subject to change in the sole discretion of the Hospital: Participating Employer Date of Participation Date of Termination of Participation Texas Children's Hospital 05/01/1987 Texas Children's Pediatric Associates, Inc. 08/15/1994 Texas Children's Health Plan, Inc. 12/07/1995 Texas Children's Home Health Services, Inc. 08/01/ /30/2007 Texas Children's Women's Specialists 01/28/2008 Texas Children's Physicians Group (dba Texas Children's Physician Services Organization) 10/01/2008 Exhibit A-1

18 EXHIBIT B/PART 1 TEXAS CHILDREN'S HOSPITAL EMPLOYEE MEDICAL CLINIC AND EMPLOYEE ASSISTANCE PROGRAM ERISA Plan Information Plan Name: Texas Children s Hospital Employee Medical Clinic and Employee Assistance Program Plan Sponsor: Texas Children s Hospital 6621 Fannin Street, Houston, Texas Employer Identification Number: Plan Number: 505 Type of Plan: Welfare plan providing access to benefits through an employee medical clinic and under an employee assistance program. Plan Administrator: Benefits Committee 6621 Fannin Street, Houston, Texas (832) Claims Administrator: With respect to each of the following Component Benefit Programs, the Plan Administrator has delegated its responsibility for determining claims under the applicable Component Benefit Program to the following entities, known as the Claims Administrators: Employee Assistance Program Texas Children s Hospital 6621 Fannin Street, Houston, Texas (832) Employee Medical Clinic Texas Children s Hospital 6621 Fannin Street, Houston, Texas (832) Exhibit B/Part 1-1

19 EXHIBIT B/PART 1 Type of Administration: With respect to each of the following Component Benefit Programs, the Plan Administrator has delegated its responsibility for the daily administration of the applicable Component Benefit Program to the following entities: Employee Assistance Program The Plan is administered by Texas Children s. Employee Medical Clinic The Plan is managed by Texas Children s. Agent for Legal Services: Texas Children s Hospital c/o General Counsel 6621 Fannin Street Houston, Texas Service of process may also be made upon the Plan Administrator. Plan Year: The period with respect to which records for the Plan are maintained. The Plan Year is the twelve (12) month period ending each December 31. Funding and Contributions: All benefits are paid from the general assets of the Employers. That is, the cost of maintaining and providing access to the Clinic and EAP is borne solely by the Employers; no participant contributions are required. Exhibit B/Part 1-2

20 EXHIBIT B/PART 2 TEXAS CHILDREN'S HOSPITAL EMPLOYEE MEDICAL CLINIC AND EMPLOYEE ASSISTANCE PLAN Statement of ERISA Rights The following Component Benefit Plans are subject to ERISA: o The Employee Medical Clinic, and o The Employee Assistance Program As a Participant in the Component Benefit Programs described above, you are entitled to certain rights and protections under ERISA. ERISA provides that all plan participants in such plans shall be entitled to: Receive Information About your Plan and Benefits. Examine, without charge, at the Plan Administrator's office and at other specified locations, all documents governing the Plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefit Security Administration, if any. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial report, if one is filed. The Plan Administrator is required by law to furnish each Participant with a copy of this summary annual report. Continuation Group Health Plan Coverage. Continue health care coverage for yourself, your Spouse or eligible dependent children if there is a loss of coverage under a group health plan as a result of a Qualifying Event (see EXHIBIT D). You, your Spouse and eligible dependent children may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries. In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants and beneficiaries. No one, including your employer, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Exhibit B/Part 2-1

21 EXHIBIT B/PART 2 Enforce Your Rights. If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules described in EXHIBIT C. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within thirty (30) calendar days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court, if you have exhausted the Plan's claims procedures. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court, if you have exhausted the Plan's claims procedures. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Questions. If you have any questions about the Plan you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C., You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. Exhibit B/Part 2-2

22 EXHIBIT C TEXAS CHILDREN'S HOSPITAL EMPLOYEE MEDICAL CLINIC AND EMPLOYEE ASSISTANCE PROGRAM Claims and Appeals Procedures For purposes of the Plan and this Summary and subject to the requirements of applicable law, claims and appeals procedures for the Plan are as follows: Claims Automatically Filed Providers will submit your claims directly to the Claim Administrator for services provided to you or any of your covered Dependents. Who Receives Payment Benefit payments will be made directly to Providers when they bill the Claim Administrator. Payment to your Provider will be considered in satisfaction of its obligations to you under the Plan. An Explanation of Benefits summary is sent to you so you will know what has been paid. Receipt of Claims by the Claim Administrator A claim will be considered received by the Claim Administrator for processing upon actual delivery to the Claim Administrator in the proper manner and form and with all of the information required. If the claim is not complete, it may be denied or the Claim Administrator may contact the Provider for the additional information. REVIEW OF CLAIM DETERMINATIONS Claim Determinations When the Claim Administrator receives a properly submitted claim, it has authority and discretion under the Plan to interpret and determine benefits in accordance with the Plan provisions. The Claim Administrator will receive and review claims for benefits and will accurately process claims consistent with administrative practices and procedures established in writing between the Claim Administrator and the Plan Administrator. You have the right to seek and obtain a full and fair review by the Claim Administrator of any determination of a claim or any other determination made by the Claim Administrator in accordance with the benefits and procedures detailed in your Plan. If a Claim Is Denied or Not Paid in Full On occasion, the Claim Administrator may deny all or part of your claim. There are a number of reasons why this may happen. We suggest that you review the SPD to see whether you understand the reason for the determination. If you have additional information that you believe Exhibit C-1

23 EXHIBIT C could change the decision, send it to the Claim Administrator and request a review of the decision as described in Claim Appeal Procedures below. If the claim is denied in whole or in part, you will receive a written notice from the Claim Administrator with the following information, if applicable: The reasons for determination; A reference to the Plan provisions on which the determination is based, or the contractual, administrative or protocol for the determination; A description of additional information which may be necessary to perfect an appeal and an explanation of why such material is necessary; and An explanation of the Claim Administrator's internal review/appeals and external review processes (and how to initiate a review/appeal or, if applicable, external review) and a statement of your right, if any, to bring a civil action under Section 502(a) of ERISA following a final denial on internal review/appeal. With respect to the benefits under the EAP, your written notice of denial will also include the following information, to the extent applicable: Subject to privacy laws and other restrictions, if any, the identification of the claim, date of service, health care provider, claim amount (if applicable), and a statement describing denial codes with their meanings and the standards used. Upon request, diagnosis/treatment codes with their meanings and the standards used are also available; In certain situations, a statement in non-english language(s) that written notices of claim denials and certain other benefit information may be available (upon request) in such non-english language(s); In certain situations, a statement in non-english language(s) that indicates how to access the language services provided by the Claim Administrator; The right to request, free of charge, reasonable access to and copies of all documents, records and other information relevant to the claim for benefits; Any internal rule, guideline, protocol or other similar criterion relied on in the determination, or a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge upon request; An explanation of the scientific or clinical judgment relied on in the determination as applied to claimant's medical circumstances, if the denial was based on medical necessity, experimental treatment or similar exclusion, or a statement that such explanation will be provided free of charge upon request; Exhibit C-2