Laws Protecting Your Journey

Transcription

1 Laws Protecting Your Journey Please read the following information to understand your rights under Houston Methodist benefits plans. References to Plan Administrator refer to the Director of Benefits at Houston Methodist. The following notices are included in this packet: Health Insurance Marketplace Coverage Options and Your Health Coverage... 2 HIPAA Notice of Special Enrollment Rights... 3 Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice of Privacy Practices... 4 Notice of Privacy Practices for the Comprehensive Welfare Benefits Plan of Houston Methodist... 4 Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)... 8 Prescription Drug Coverage and Medicare (Medicare Part D) Women s Health and Cancer Rights Act The Newborns and Mothers Health Protection Act (Newborns Act) Mental Health Parity and Addiction Equity Notice Right to Designate a Primary Care Provider Notice Summary of Benefits and Coverage Available Workers Compensation Qualified Medical Child Support Order (QMCSO) Premium Assistance under Medicaid and the Children s Health Insurance Program (CHIP) Your Rights Under the Family Medical Leave Act of 1993 (FMLA) Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) The Employee Retirement Income Security Act of 1974 (ERISA)... 22

2 Health Insurance Marketplace Coverage Options and Your Health Coverage Key parts of the Affordable Care Act, also known as the health care reform law, went into effect on January 1, 2014, offering a new way to buy health insurance: the Health Insurance Marketplace (the Marketplace, also sometimes called the exchange ). To assist you as you evaluate options for you and your family, this notice provides basic information about the new Marketplace and employment-based health coverage offered by Houston Methodist. We ve made sure that the health coverage available through Houston Methodist provides you with comprehensive, affordable coverage, which means our employee health care plan is likely to be your most costeffective option and not the Health Insurance Marketplace. However, U.S. employers are required to send this notice to employees to raise awareness of the new Marketplace and to help them understand how having access to their employer s health care plan may limit their eligibility for federal subsidies in the Marketplace. What Is the Health Insurance Marketplace? The Marketplace is designed to help individuals find health insurance that meets their needs and fits their budget. It offers one-stop shopping to find and compare private health insurance options. Individuals may also be eligible for a new kind of tax credit that lowers their monthly premium right away. All U.S. citizens and legal residents will have access to individual health insurance policies through the Marketplace in their state. Open enrollment for health insurance coverage through the Marketplace begins in October 2014 for coverage starting January 1, Can I Save Money on Health Insurance Premiums in the Marketplace? Some people who do not have access to affordable, minimum-value health care coverage through their employer may be eligible for federal subsidies in order to make buying insurance through the Marketplace more affordable. Eligibility for these federal subsidies depends on household income. It s important to note that because the Houston Methodist health care plan options meet the government s standards for minimum value and affordability, you likely will not qualify for federal subsidies if you are eligible for Houston Methodist benefits. Does Employer Health Coverage Affect Eligibility for Federal Subsidies through the Marketplace? Yes. If you have health coverage available through Houston Methodist, you are likely not eligible for federal subsidies through the Marketplace. You may be eligible for a tax credit that lowers your monthly premiums or a reduction in certain cost-sharing if the cost of the lowest cost Employee-only Houston Methodist Medical Plan option $1, per year for the Choice Plan Option is more than 9.5% of your annual household income. What If I m Not Eligible for the Houston Methodist Medical Plan? If you are not eligible for the Houston Methodist Medical Plan, you should consider other options available to you, such as coverage through your spouse s employer plan, your parent s employer plan (if you are under age 26), Medicaid, Medicare or your state s Marketplace. Enrollment in the Marketplace will begin in October If you have questions about your Houston Methodist benefits, visit mymethodistbenefits.com or contact HR Benefits at or hrbenefits@houstonmethodist.org. 2

3 If you decide to enroll through the Marketplace, you will need to provide the Marketplace with the following information about Houston Methodist and our health care plans: Employer name: Houston Methodist Employer Identification Number EIN: Employer address: 6565 Fannin, GB 164, Houston, Texas Employer telephone number: Name of contact for employee health coverage: HR Benefits at Phone number of contact (if different from above): address of contact: Important Note: If you purchase a medical plan through the Marketplace instead of accepting health coverage offered by Houston Methodist, then you will lose Houston Methodist s contribution to the company-offered coverage. Also, this contribution as well as your employee contribution to employer-offered coverage is often excluded from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? If you d like to learn more about the Health Insurance Marketplace in your state, please visit the website sponsored by the Department of Health and Human Services, for more information. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. If you decide to shop for coverage in the Marketplace, will guide you through the process. HIPAA Notice of Special Enrollment Rights THIS NOTICE DESCRIBES SPECIAL CIRCUMSTANCES WHICH MAY ALLOW YOU AND YOUR ELIGIBLE DEPENDENTS TO ENROLL IN HOUSTON METHODIST COMPANY GROUP HEALTH COVERAGE DURING THE YEAR. PLEASE REVIEW IT CAREFULLY. Houston Methodist sponsors a group health plan (the Plan ) to provide coverage for health care services for our employees and their eligible dependents. Our records show that you are eligible to participate, which requires that you complete enrollment in the Plan and pay your portion of the cost of coverage through payroll deductions or decline coverage. A federal law called HIPAA requires we notify you about your right to later enroll yourself and eligible dependents for coverage in the Plan under special enrollment provisions described below. Special Enrollment Provisions Loss of Other Coverage. If you decline enrollment for yourself or for an eligible dependent because you had other group health plan coverage or other health insurance, you may be able to enroll yourself and your dependents in the Plan if you or your dependents lose eligibility for that other coverage, or if the other employer stops contributing toward your or your dependents other coverage. You must request enrollment within 60 days after you or your dependents other coverage ends, or after the other employer stops contributing toward the other coverage. Please contact Houston Methodist HR Benefits at or hrbenefits@houstonmethodist.org for details, including the effective date of coverage added under this special enrollment provision (contact information provided below). New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. If you gain a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents in the Plan. You must request enrollment within 60 days after the marriage, birth, adoption, or placement for adoption. In the event you acquire a new dependent by birth, adoption, or placement for adoption, you may also be able to enroll your spouse in the Plan, if your spouse was not previously covered. Please contact Houston Methodist HR Benefits at or hrbenefits@houstonmethodist.org for details, including the effective date of coverage added under this special enrollment provision (contact information provided below). 3

4 Enrollment Due to Medicaid/CHIP Events. If you or your eligible dependents are not already enrolled in the Plan, you may be able to enroll yourself and your eligible dependents in the Plan if: (i) you or your dependents lose coverage under a state Medicaid or children s health insurance program (CHIP), or (ii) you or your dependents become eligible for premium assistance under state Medicaid or CHIP. You must request enrollment within 60 days from the date of the Medicaid/CHIP event. Please contact Houston Methodist HR Benefits at or hrbenefits@houstonmethodist.org for details, including the effective date of coverage added under this special enrollment provision (contact information provided below). Contact Information If you have any questions about this Notice or about how to enroll in the Plan, please contact Houston Methodist HR Benefits at or hrbenefits@houstonmethodist.org or by writing to: Houston Methodist Houston Methodist HR Benefits 6565 Fannin, GB 164 Houston, TX Notice Availability A copy of this notice is available at our website, mymethodistbenefits.com. Additional information regarding your rights to enroll in the Plan are found in the applicable summary plan description(s) for the Plan, or you may contact Houston Methodist HR Benefits at or hrbenefits@houstonmethodist.org as provided above for more information. Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice of Privacy Practices Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Houston Methodist health care plans (the Plan ) are required to provide you with a HIPAA Notice of Privacy Practices ( Notice ) at the time of your enrollment and at certain other times. In addition, the Plan is required to periodically notify you of the availability of the Notice and provide you with information on how to obtain a copy of the Notice. You may obtain a copy of the Plan s Notice at any time by accessing mymethodistbenefits.com. To request a paper copy of this notice, contact HR Benefits at or hrbenefits@houstonmethodist.org, Monday Friday, 7:30 a.m. 5 p.m. To the extent that the Plan contains benefits other than those covered under HIPAA s privacy rules, this reminder pertains only to those health care benefits that are covered under HIPAA s privacy rules. Note: If you are covered by one or more fully-insured group health plans offered by Houston Methodist, you will receive a separate note regarding the availability of the Notice and how to obtain a copy of the Notice directly from the insurance carrier(s). Notice of Privacy Practices for the Comprehensive Welfare Benefits Plan of Houston Methodist This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This notice of Privacy Practices identifies the general ways your protected health information can be used or disclosed. Protected health information is the individually identifiable personal health information found in your medical and billing records. This information is created or received by a health care provider, insurance company, 4

5 or employer, and relates to your past, present, or future physical or mental health conditions. This information can be transmitted or maintained in any form by Houston Methodist. As used in this notice, the term Plan refers to the Comprehensive Welfare Benefits Plan of Houston Methodist, the term Participant refers to an individual who is a Participant in the Plan and thereby entitled to health benefits under the Plan and the term Potential Participant refers to an individual who may at some time become a Participant but who is not yet a Participant. If you have any questions about this notice, please contact the Privacy Officer of the Plan. This notice describes your legal rights regarding your health information. It also informs you of the legal duties and privacy practices of Houston Methodist and its Plan with respect to your health information created by virtue of your participation in the Plan. Our Legal Duties We are required, by law, to keep your identifiable health information private; provide you with this Notice of our legal duties and privacy practices with respect to your health information; and follow the terms of the Notice as long as it is in effect. If we revise this Notice, we will follow the terms of the revised Notice, as long as it is in effect. How We May Use and Disclose Your Health Information The following information describes how we are permitted, or required by law, to use and disclose your health information. Not every use or disclosure in a category will be listed. Treatment The Plan may receive, use and disclose health information about you to help you obtain health treatment or services. For example, the Plan may request and receive from a doctor who is treating you information about the health condition for which you are seeking treatment in order to determine if the treatment you are seeking (for instance, cosmetic surgery) is or is not covered by the Plan. Payment The Plan may receive, use and disclose health information about you so that the bills for health treatment and services you have received may be paid by the Plan. For example, the Plan may need to be provided with information about a surgery you received, in order to determine if the charges exceed the reasonable and customary charges for such surgery and to determine what portion of the bill submitted for the surgery should be paid by the Plan. The Plan might also need to receive information about a health condition you have, in advance of a procedure for that condition, when pre-procedure approval is required in order to qualify for any Plan payment for the procedure or for Plan payment at a more favorable reimbursement rate for the procedure. The Plan may receive use and disclose health information to fiduciaries of the Plan in order to provide them with information necessary to process and determine any claims you may make for Plan benefits or appeals that you may make of claims for Plan benefits, which have been denied. The Plan may also use and disclose health information to coordinate with other health plans to determine coverage benefits for your claim. For Health Care Operations The Plan may receive, use and disclose health information about you for purposes of underwriting, premium rating or other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits. For instance, the Plan may request from any insurer currently funding or providing benefits under the Plan, information relating to your and other Plan Participants health procedures and treatments over a prior period, in order to provide other insurers with information to make knowledgeable bids to ensure Plan benefits for future periods. The Plan is prohibited from using or disclosing health information that is genetic information about an individual for underwriting purposes. Health and Wellness Information We may use your PHI to contact you with information about: treatment alternatives; therapies; health care providers; settings of care; or other health-related benefits, services and products that may be of interest to you. For example, we might send you information about tobacco/nicotine cessation programs. 5

6 Plan Sponsor Information Request The Plan may disclose to Houston Methodist, (the Plan Sponsor) at their request, any summary health information (i.e., information that summarizes the claims history, claims expenses or type of claims experienced by covered persons under the Plan) for the purpose of obtaining premium bids for providing health insurance coverage under the Plan or modifying, amending or terminating the Plan. For example, the Plan Sponsor may request summary health information about Plan Participants claims over a given period to determine ways in which the Plan might be amended in the future to reduce costs of providing the Plan. The following is an alphabetical listing of the other types of uses and disclosures of health information that may be made by the Plan: As Required by Law The Plan will use or disclose health information about you when required by Federal, state, or local law. Business Associates Houston Methodist may contract with an entity to perform services on behalf of the Plan. The Plan may then disclose your health care information to such Business Associate. The Business Associate will use or disclose your health information only to the extent the Plan would be able to do so, under the terms of this Section. Health-related Benefits and Services The Plan may contact you to give you information about healthrelated benefits and services that may interest you. Individuals Involved in Your Care or Payment for Your Care The Plan may use or disclose your health information to notify a relative, personal representative, or other person responsible for your care, about your location and general condition. The Plan will also disclose your health information to your relative, close personal friend, or any other person you identify, if the information relates to that person s involvement with your health care or payment for your health care. Public Health and Safety We may use or disclose health information, as authorized or required by local, State or Federal law, for the following purposes deemed to be in the public interest or benefit: To report certain diseases and wounds, births and deaths, and suspected cases of abuse, neglect, or domestic violence To help identify, locate, or report criminal suspects, crime victims, suspicious deaths, or criminal conduct on Houston Methodist s premises To respond to a court order, subpoena, or other judicial process To assist Federal disaster relief efforts To enable product recalls, repairs, or replacements To respond to an audit, inspection, or investigation by a health-related government agency To assist in Federal intelligence, counterintelligence, and national security issues To facilitate organ and tissue donations To assist coroners, medical examiners, and funeral directors To respond to a request from a jail or prison regarding an inmate s health or medical treatment To respond to a request from your military command authority (if you are a member or veteran of the armed forces) To provide information to a workers compensation program Research The Plan will disclose information to researchers in preparation for a research study or after the research has been approved by an Institutional Review Board or Privacy Board. These Boards review the research proposal and establish protocols to ensure the privacy of your health information. Secretary of Health and Human Services As required by law, the Plan will disclose health information to the Secretary of Health and Human Services, a Federal agency that investigates compliance with Federal privacy law. 6

7 Serious Threat to Health and Safety The Plan may use or disclose your health information if necessary because of a serious threat to someone s health or safety. Workers Compensation The Plan will disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or similar programs providing benefits for work-related injuries or illnesses. Your Health Information Rights You have the following rights, with certain exceptions, regarding your health information that is maintained by the Plan. Authorizations Other uses or disclosures of your health information not described above, including the use and disclosure of psychotherapy notes and the use or disclosure of health information for fundraising or marketing purposes, will not be made without your written authorization. You may revoke written authorization at any time, so long as your revocation is in writing. Once we receive your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation. You may elect to opt out of receiving fundraising communications from us at any time. Confidential Communications You have the right to request that we communicate health information to you by an alternate means or location other than your home address and telephone number. Your request must be made in writing to the Plan s contact person, and must specify how or where you wish to be contacted. We will try to accommodate your request for alternate communications. If you request an alternate means of communication, that request also should be communicated by you to all of your physicians, including your private physician. Restrictions You have the right to request that we restrict the use or disclosure of your health information for treatment, payment, or health care operations. While we are not required to agree to your request, if we do agree, your request will be complied with, unless the information is needed to provide emergency treatment to you. Your request must be made in writing to our listed contact person. You have the right to a paper copy of this Notice. In addition, a copy of this Notice also may be obtained at our web site, mymethodistbenefits.com. Also, if you have any questions or need information regarding our legal duties and privacy practices, or how to exercise any of your health information rights listed in this Notice, please contact: Business Practices Officer Houston Methodist 1130 Earle Street, AX200 Houston, Texas Access You have the right to review and obtain a copy of your health information, with certain exceptions. Usually, this includes medical and billing records, but does not include psychotherapy notes. Your request to review or obtain a copy of your health information must be in writing to our listed contact person. You will be charged fees for processing, copying, and postage as authorized by Texas State law. Amendment If you feel that the health information we have about you is incorrect or incomplete, you have the right to ask for an amendment of that information. You have the right to request an amendment for as long as the information is kept by or for us. Your request for an amendment must be made in writing to our listed contact person, and include a reason that supports your request. Accounting of Disclosures You have the right to request a list of disclosures that we have made of your health information, except for disclosures made for treatment, payment or health care operations, those authorized by you, and certain other disclosures. Your request must be in writing to our listed contact person, and must state a time period for which you want an accounting. The time period may not be longer than six years, and may not include dates before April 14, The first accounting you request within a twelve-month period will be free. A fee will be charged for additional lists within this same time period. 7

8 Breach Notification In certain instances, you have the right to be notified in the event that we, or one of our Business Associates, discover an inappropriate use or disclosure of your health information. Notice of any such use or disclosure will be made in accordance with state and federal requirements. Revisions of this Notice We reserve the right to change this Notice, and the right to make the new provisions effective for all health information we currently maintain, as well as any information we receive in the future. If we make a major change to this Notice, the revised Notice will be posted and on our web site. In addition, a paper copy of the revised Notice will be available upon request. To Report a Complaint If you believe your health information privacy rights have been violated, you can file a complaint with us or with the Secretary of the United States Department of Health and Human Services. There will not be any penalty or retaliation against you for making a complaint to us or to the Department of Health and Human Services. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) Continuation of Coverage If you lose coverage, you may have the right to extend it under the Consolidated Budget Reconciliation Act of 1985 (COBRA). Continuation coverage under COBRA is available only to benefit plans that are subject to the terms of COBRA. At Houston Methodist, the medical plans, vision plan, dental plans, employee assistance program (EAP), and health care flexible spending account are subject to the provisions of COBRA. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse s plan), even if that plan generally doesn t accept late enrollees. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at Continuation Coverage under Federal Law (COBRA) Much of the language in this section comes from the Federal law that governs continuation coverage. You should call your Plan Administrator if you have questions about your right to continue coverage. In order to be eligible for continuation coverage under Federal law, you must meet the definition of a Qualified Beneficiary. A Qualified Beneficiary is any of the following persons who were covered under the Plan on the day before a qualifying event: A Participant; A Participant s enrolled dependent, including with respect to the Participant s children, a child born to or placed for adoption with the Participant during a period of continuation coverage under Federal law; or A Participant s former spouse. You will have up to 60 days from the date you receive notification or 60 days from the date your coverage ends to elect COBRA coverage, whichever is later. You will then have an additional 45 days to pay the cost of your COBRA coverage, retroactive to the date your Plan coverage ended. 8

9 Qualifying Events for Continuation Coverage under COBRA The table on the following page outlines situations in which you may elect to continue coverage under COBRA for yourself and your dependents, and the maximum length of time you can receive continued coverage. These situations are considered qualifying events. If Coverage Ends Because of the Following Qualifying You may Elect COBRA: Events : For Yourself For Your Spouse For Your Child(ren) Your work hours are reduced 18 months 18 months 18 months Your employment terminates for any reason (other than 18 months 18 months 18 months gross misconduct) You or your family member become eligible for Social 29 months 29 months 29 months Security disability benefits at any time within the first 60 days of losing coverage 1 You die N/A 36 months 3 36 months 3 You divorce (or legally separate) N/A 36 months 36 months Your child is no longer an eligible family member (e.g., N/A N/A 36 months reaches the maximum age limit) You become entitled to Medicare N/A See Medicare See Medicare table table The Plan Sponsor files for bankruptcy under Title 11, N/A 36 months 36 months United States Code 2 1. Subject to the following conditions: (i) notice of the disability must be provided within the latest of 60 days after a) the determination of the disability, b) the date of the qualifying event, c) the date the Qualified Beneficiary would lose coverage under the Plan, and in no event later than the end of the first 18 months; (ii) the Qualified Beneficiary must agree to pay any increase in the required premium for the additional 11 months over the original 18 months; and (iii) if the Qualified Beneficiary entitled to the 11 months of coverage has non-disabled family members who are also Qualified Beneficiaries, then those non-disabled Qualified Beneficiaries are also entitled to the additional 11 months of continuation coverage. Notice of any final determination that the Qualified Beneficiary is no longer disabled must be provided within 30 days of such determination. Thereafter, continuation coverage may be terminated on the first day of the month that begins more than 30 days after the date of that determination. 2. This is a qualifying event for any retired Participant and his or her enrolled Dependents if there is a substantial elimination of coverage within one year before or after the date the bankruptcy was filed. 3. From the date of the Participant s death if the Participant dies during the continuation coverage. If you or your Dependents fail to notify the Plan Administrator of a Qualifying COBRA Event within 60 days, the Plan Administrator is not obligated to provide continued coverage to the affected Qualified Beneficiary. If you are continuing coverage under COBRA, you must notify the Plan Administrator within 60 days of the birth or adoption of a child. How Your Medicare Eligibility Affects Dependent COBRA Coverage The table below outlines how your Dependents COBRA coverage is impacted if you become entitled to Medicare. If Dependent Coverage Ends When: You May Elect COBRA Dependent Coverage For Up To: You become entitled to Medicare and don t experience any additional qualifying 18 months events You become entitled to Medicare, after which you experience a second qualifying 36 months event* before the initial 18-month period expires You experience a qualifying event*, after which you become entitled to Medicare 36 months before the initial 18-month period expires; and, if absent this initial qualifying event, your Medicare entitlement would have resulted in loss of Dependent coverage under the Plan * Your work hours are reduced or your employment is terminated for reasons other than gross misconduct. 9

10 Trade Act of 2002 The Trade Act of 2002 amended COBRA to provide for a special second 60-day COBRA election period for certain Participants who have experienced a termination or reduction of hours and who lose group health plan coverage as a result. The special second COBRA election period is available only to a very limited group of individuals: generally, those who are receiving trade adjustment assistance (TAA) or alternative trade adjustment assistance under a Federal law called the Trade Act of These Participants are entitled to a second opportunity to elect COBRA coverage for themselves and certain family members (if they did not already elect COBRA coverage), but only within a limited period of 60 days from the first day of the month when an individual begins receiving TAA (or would be eligible to receive TAA but for the requirement that unemployment benefits be exhausted) and only during the six months immediately after their group health plan coverage ended. If a Participant qualifies or may qualify for assistance under the Trade Act of 1974, he or she should contact the Plan Administrator for additional information. The Participant must contact the Plan Administrator promptly after qualifying for assistance under the Trade Act of 1974 or the Participant will lose his or her special COBRA rights. COBRA coverage elected during the special second election period is not retroactive to the date that Plan coverage was lost, but begins on the first day of the special second election period. Getting Started You will be notified by mail if you become eligible for COBRA coverage as a result of a reduction in work hours or termination of employment. The notification will give you instructions for electing COBRA coverage, and advise you of the monthly cost. Your monthly cost is the full cost, including both Participant and Employer Costs, plus a 2% administrative fee or other cost as permitted by law. While you are a participant in the medical, vision, and/or dental plan under COBRA, you have the right to change your coverage election: During the 60-day election period, the Plan will, only in response to a request from a Provider, inform that Provider of your right to elect COBRA coverage, retroactive to the date your COBRA eligibility began. Notification Requirements If your covered dependents lose coverage due to divorce, legal separation, or loss of dependent status, you or your dependents must notify the Plan Administrator within 60 days of the latest of: During Open Enrollment; and Following a change in family status. The date of the divorce, legal separation or an enrolled dependent s loss of eligibility as an enrolled dependent; The date your enrolled dependent would lose coverage under the Plan; or The date on which you or your enrolled dependent are informed of your obligation to provide notice and the procedures for providing such notice. You or your dependents must also notify the Plan Administrator when a qualifying event occurs that will extend continuation coverage. Once you have notified the Plan Administrator, you will then be notified by mail of your election rights under COBRA. Notification Requirements for Disability Determination If you extend your COBRA coverage beyond 18 months because you are eligible for disability benefits from social security, you must provide WageWorks (Houston Methodist s COBRA vendor) with notice of the social security administration s determination within 60 days after you receive that determination, and before the end of your initial 18-month continuation period. 10

11 For events other than disability, the notice requirements will be satisfied by providing written notice to the Plan Administrator at 6565 Fannin, GB 164, Houston, Texas, For disability, written notice must be provided to WageWorks. For more information, please contact WageWorks by calling The contents of the notice must be such that the Plan Administrator is able to determine the covered Participant and qualified beneficiary(ies), the qualifying event or disability, and the date on which the qualifying event occurred. None of the notice requirements will be enforced if the participant or dependent is not informed of his or her obligations to provide such notice. When COBRA Ends COBRA coverage will end before the maximum continuation period shown previously if: You or your covered dependent becomes covered under another group medical plan, as long as the other plan doesn t limit your coverage due to a pre-existing condition; or if the other plan does exclude coverage due to your pre-existing condition, your COBRA benefits would end when the exclusion period ends. The other group health coverage will be primary for all health services except those health services that are subject to the pre-existing condition limitation or exclusion. You or your covered dependent becomes eligible for Medicare after electing COBRA; The first required premium is not paid within 45 days; Any other monthly premium is not paid within 31 days of its due date; The entire Plan ends; or Coverage would otherwise terminate under the Plan as described in the beginning of this section. NOTE: If you selected continuation coverage under a prior plan which was then replaced by coverage under this Plan, continuation coverage will end as scheduled under the prior plan or in accordance with the terminating events listed in this section, whichever is earlier. Prescription Drug Coverage and Medicare (Medicare Part D) Important Notice from Houston Methodist About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This Remember: notice has information about your current prescription drug coverage with Houston Methodist and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Houston Methodist has determined that the prescription drug coverage offered by the Houston Methodist Employee Medical Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your 11

12 existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Houston Methodist coverage will not be affected. If you do decide to enroll in a Medicare prescription drug plan and drop your Houston Methodist prescription drug coverage, be aware that you may not be able to get this coverage back. If you drop your coverage with Houston Methodist and enroll in a Medicare prescription drug plan, you may not be able to get this coverage back later. If you remain an active employee or on a leave of absence, you will be able to re-enroll in the medical plan that includes your current prescription drug benefit at open enrollment. However, if you are continuing coverage through COBRA, you will not be able to re-enroll once you cancel your current Houston Methodist coverage. You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. Under your current medical plan, after you pay an annual pharmacy deductible of $50, you may purchase a one-month supply (up to 30 days) of a generic drug at your local pharmacy for a $10 co-pay, preferred brand name drug for 30% coinsurance (Min $35 Max $75), and non-preferred brand name drug for 50% coinsurance (Min $50 Max $125). You may also purchase a 90- day supply of a maintenance prescription drug through mail order for a $20 co-pay for a generic drug, 30% coinsurance (Min $70 Max $150) for a preferred brand name drug, and 50% coinsurance (Min $100 Max $250) for a non-preferred brand-name drug. In addition, your current coverage pays for other health expenses, in addition to prescription drugs, and you may or may not be eligible to receive all of your current health and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan: If you are currently enrolled in a Houston Methodist medical plan as a COBRA participant but are not currently a Medicare participant and become enrolled in Medicare and a Medicare prescription drug program, you will not be able to continue your current Houston Methodist health and prescription drug benefits. If you are currently enrolled in a Houston Methodist medical plan as a COBRA participant and you are also enrolled in Medicare and you choose to enroll in a Medicare prescription drug plan, you will be able to continue your current Houston Methodist health and prescription drug benefits. If you are an active employee on a leave of absence and either you are enrolled or become enrolled in Medicare, and you choose to enroll in a Medicare prescription drug plan, you will be able to continue coverage under your Houston Methodist health and prescription drug benefits. When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Houston Methodist and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this 12

13 higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information about This Notice or Your Current Prescription Drug Coverage Contact the person listed below for further information or contact HR Benefits at or NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Houston Methodist changes. You also may request a copy of this notice at any time. Date: 10/01/2014 Name of Entity/Sender: Houston Methodist / June McPhail Contact/Position/Office: Manager, Benefits Administration Address: 6565 Fannin, GB164, Houston, Texas Phone Number: For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (TTY ). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Women s Health and Cancer Rights Act The Women s Health and Cancer Rights Act (WHCRA), signed into law on October 21, 1998, contains protections for patients who elect breast reconstruction in connection with a mastectomy. For plan participants and beneficiaries receiving benefits in connection with a mastectomy, plans offering coverage for a mastectomy must also cover reconstructive surgery and other benefits related to a mastectomy. WHCRA: Applies to group health plans for plan years starting on or after October 22, 1998 Applies to group health plans, health insurance companies or HMOs, if the plan or coverage provides medical and surgical benefits with respect to a mastectomy Requires coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient Under WHCRA, mastectomy benefits must include coverage for: All stages of reconstruction of the breast on which the mastectomy was performed 13

14 Surgery and reconstruction of the other breast to produce a symmetrical appearance Prostheses and treatment of physical complications at all stages of mastectomy, including lymph edemas Under WHCRA, mastectomy benefits may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage. The law also contains prohibitions against: Plans and issuers denying eligibility or continued eligibility to enroll or renew coverage under the plan to avoid the requirements of WHCRA Plans and issuers providing incentives to, or penalizing, physicians to induce them to provide care in a manner inconsistent with the WHCRA The Houston Methodist Medical Plan is covered by the law and provides benefits accordingly. Questions about this law or mastectomy related benefits covered under the medical plans of Houston Methodist should be directed to your HR department or HR Benefits at or hrbenefits@houstonmethodist.org. The Newborns and Mothers Health Protection Act (Newborns Act) Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Mental Health Parity and Addiction Equity Notice Houston Methodist s group medical plans provide and administer mental health and substance abuse benefits as required by the Mental Health Parity and Addiction Equity Act of 2008 ( MHPAEA ). For more information about Houston Methodist s group medical plans and their compliance under the MHPAEA, please contact the HR Benefits at or hrbenefits@houstonmethodist.org, Monday Friday, 7:30 a.m. 5 p.m. Right to Designate a Primary Care Provider Notice Houston Methodist allows, but does not require, the designation of a primary care provider. You have the right to designate any primary care provider who participates in the UnitedHealthcare network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact UnitedHealthcare at the number listed on the back of your member ID card or online at For children, you may designate a pediatrician as the primary care provider. Summary of Benefits and Coverage Available As an employee, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury Your plan offers a series of health coverage options. Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options. The SBC is available on the web at mymethodistbenefits.com. A paper copy is also available, free of charge, by contacting Houston Methodist HR Benefits at or at hrbenefits@houstonmethodist.org. 14

15 Workers Compensation Houston Methodist has workers compensation insurance coverage to protect you in the event of a work-related injury or illness. an employee or a person acting on the employee s behalf must notify the employer of an injury or illness no later than the 30th day after the date on which the injury occurs or the date the employee knew or should have known of an illness, unless the Texas Department of Insurance Division of Workers Comp. determines that good cause existed for failure to provide timely notice. Houston Methodist is required to provide you with coverage information, in writing, when you are hired or whenever Houston Methodist becomes, or ceases to be, covered by workers compensation insurance. Qualified Medical Child Support Order (QMCSO) Federal law requires Houston Methodist, under certain circumstances, to provide health care coverage for your child(ren) when you divorce, separate, or are even never married, when ordered to do so by State authorities. The process begins when Houston Methodist receives a medical child support order. This means any judgment, decree, or order, including approval of a settlement agreement, which: Is issued from a court of competent jurisdiction or through an administrative process established under State law and has the force and effect of an order under State law pursuant to a state s domestic relations law. Requires you to provide group health coverage for your child(ren), even though you no longer have custody. Clearly specifies your name and last known mailing address and the name and addresses of a child covered by the order. The name and mailing address of a State or local official may be substituted for the address of the child. A reasonable description of the coverage to be provided. The length of time the order applies. If Houston Methodist receives a QMCSO, it must permit immediate enrollment. This means the child(ren) identified will be included for coverage as your eligible dependent and you will pay the required premiums. The child s custodial parent, legal guardian, or a state agency can make application for the child s coverage, even if you do not. The Plan Administrator will provide written notification to you and each identified child for which it has received an order requiring coverage. Within a reasonable time after the receipt of the order, the Plan Administrator will determine whether the order is a Qualified Medical Child Support Order (QMCSO) and notify you and the child s legal representative of the determination. This notice will include any required enrollment material, a description of the procedures to be followed, and a form for designating the child s custodial parent or legal guardian as his or her representative for all benefit plan purposes. Plan benefits that have not been assigned will be used to reimburse charges for covered expenses incurred by an identified child. 15

16 Premium Assistance under Medicaid and the Children s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren t eligible for Medicaid or CHIP, you won t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 877.KIDS.NOW or to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. You must request coverage within 60 days of being determined eligible for premium assistance. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren t already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at or call EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, Contact your State for more information on eligibility. ALABAMA Medicaid Website: Phone: ALASKA Medicaid Website: Phone (Outside of Anchorage): Phone (Anchorage): ARIZONA CHIP Website: Phone (Outside of Maricopa County): Phone (Maricopa County): COLORADO Medicaid Medicaid Website: Medicaid Phone (In state): Medicaid Phone (Out of state): FLORIDA Medicaid Website: Phone: GEORGIA Medicaid Website: click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone:

17 IDAHO Medicaid Medicaid Website: PremiumAssistance/tabid/1510/Default.aspx Medicaid Phone: INDIANA Medicaid Website: Phone: IOWA Medicaid Website: Phone: KANSAS Medicaid Website: Phone: KENTUCKY Medicaid Website: Phone: LOUISIANA Medicaid Website: Phone: MAINE Medicaid Website: Phone: ; TTY MASSACHUSETTS Medicaid and CHIP Website: Phone: MINNESOTA Medicaid Website: Click on Health Care, then Medical Assistance Phone: MISSOURI Medicaid Website: htm Phone: MONTANA Medicaid Website: clientindex.shtml Phone: NEBRASKA Medicaid Website: Phone: NEVADA Medicaid Medicaid Website: Medicaid Phone: NEW HAMPSHIRE Medicaid Website: Phone: NEW JERSEY Medicaid and CHIP Medicaid Website: medicaid/ Medicaid Phone: CHIP Website: CHIP Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid Website: Phone: NORTH DAKOTA Medicaid Website: Phone:

18 OKLAHOMA Medicaid and CHIP Website: Phone: OREGON Medicaid Website: Phone: PENNSYLVANIA Medicaid Website: Phone: RHODE ISLAND Medicaid Website: Phone: SOUTH CAROLINA Medicaid Website: Phone: SOUTH DAKOTA Medicaid Website: Phone: TEXAS Medicaid Website: Phone: UTAH Medicaid and CHIP Website: Phone: VERMONT Medicaid Website: Phone: VIRGINIA Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: WASHINGTON Medicaid Website: /index.aspx Phone: ext WEST VIRGINIA Medicaid Website: Phone: , HMS Third Party Liability WISCONSIN Medicaid Website: htm Phone: WYOMING Medicaid Website: Phone: To see if any other states have added a premium assistance program since July 31, 2014, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration EBSA (3272) U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services , Menu Option 4, Ext OMB Control Number (expires 10/31/2016) 18

19 Your Rights Under the Family Medical Leave Act of 1993 (FMLA) Basic Leave Entitlement FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons: For incapacity due to pregnancy, prenatal medical care or child birth; To care for the employee s child after birth, or placement for adoption or foster care; To care for the employee s spouse, son or daughter, or parent, who has a serious health condition; or For a serious health condition that makes the employee unable to perform the employee s job. Military Family Leave Entitlements Eligible employees with a spouse, son, daughter, or parent on active duty or call to active duty status in the National Guard or Reserves in support of a contingency operation may use their 12-week leave entitlement to address certain qualifying exigencies. Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briefings. FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered service member during a single 12-month period. A covered service member is a current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or illness incurred in the line of duty on active duty that may render the service member medically unfit to perform his or her duties for which the service member is undergoing medical treatment, recuperation, or therapy; or is in outpatient status; or is on the temporary disability retired list. Benefits and Protections During FMLA leave, the employer must maintain the employee s health coverage under any group health plan on the same terms as if the employee had continued to work. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee s leave. Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30-days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer s normal call-in procedures Eligibility Requirements Employees are eligible if they have worked for a covered employer for at least one year, for 1,250 hours over the previous 12 months, and if at least 50 employees are employed by the employer within 75 miles. Definition of Serious Health Condition A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee s job, or prevents the qualified family member from participating in school or other daily activities. Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than three consecutive calendar days combined with at least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment. 19

20 Use of Leave An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer s operations. Leave due to qualifying exigencies may also be taken on an intermittent basis. Substitution of Paid Leave for Unpaid Leave Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In order to use paid leave for FMLA leave, employees must comply with the employer s normal paid leave policies. Employee Responsibilities Employees must provide sufficient information for the employer to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include that the employee is unable to perform job functions, the family member is unable to perform daily activities, the need for hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave. Employees also must inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be required to provide a certification and periodic recertification supporting the need for leave. Employer Responsibilities Covered employers must inform employees requesting leave whether they are eligible under FMLA. If they are, the notice must specify any additional information required as well as the employees rights and responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility. Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee s leave entitlement. If the employer determines that the leave is not FMLA-protected, the employer must notify the employee. Unlawful Acts by Employers FMLA makes it unlawful for any employer to: For Additional Information on Family Medical Leave If you have access to the Internet, visit the FMLA website: To locate your nearest Wage-Hour Office, telephone the Wage-Hour toll-free information and help line at USWAGE ( ). A customer service representative is available to assist you with referral information from 8 a.m. to 5 p.m. in your time zone; or access online at Employee Benefits Security Administration Centers for Medicare & Medicaid Services: EBSA (3272) , Ext Interfere with, restrain, or deny the exercise of any right provided under FMLA Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA Enforcement An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer. FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights. 20