State of Nevada Public Employees Benefits Program (PEBP) MEDICARE EXCHANGE HEALTH REIMBURSEMENT ARRANGEMENT (EXCHANGE HRA PLAN)

Transcription

1 State of Nevada Public Employees Benefits Program (PEBP) MEDICARE EXCHANGE HEALTH REIMBURSEMENT ARRANGEMENT (EXCHANGE HRA PLAN)

2 TABLE OF CONTENTS ARTICLE I ADOPTION AGREEMENT Name of Plan Plan Sponsor Plan Administrator Plan Number Effective Date Eligible Retiree Dependent Medical Expense Exclusion Benefit Credit Insurance Coverage Exception Account Structure Timing of Benefit Credit Carryover of Accounts Death... 3 ARTICLE II DEFINITION OF TERMS Definitions Gender and Number... 4 ARTICLE III PARTICIPATION Agreement to Participate Cessation of Participation... 5 ARTICLE IV FUNDING Funding Benefit Credits... 6 ARTICLE V BENEFITS Provision of Benefits Amount of Reimbursement Expense Reimbursement Procedure Carryover of Accounts Death... 9

3 5.6 Nondiscrimination Legal Provisions... 9 ARTICLE VI CONTINUATION COVERAGE Continuation Coverage Notices Discontinuation of Reimbursement ARTICLE VII ADMINISTRATION Administration Duties of PEBP Delegation of Duties Claims Procedure Nondiscriminatory Operation ARTICLE VIII HIPAA Purpose HIPAA Privacy Compliance HIPAA Security Compliance ARTICLE IX GENERAL PROVISIONS Amendment and Termination Adoption by Affiliates PEBP Liability Alienation of Benefits Facility of Payment Lost Distributees Status of Benefits Applicable Law Capitalized Terms Severability... 18

4 MEDICAL EXCHANGE HEALTH REIMBURSEMENT ARRANGEMENT INTRODUCTION The State of Nevada Public Employees Benefits Program (PEBP) hereby adopts this Medicare Exchange Health Reimbursement Arrangement Plan (Exchange HRA Plan) for the purpose of allowing certain retirees covered under PEBP to obtain reimbursement of eligible medical expenses incurred by such retirees and their family members. PEBP intends the Exchange HRA Plan to qualify as a health reimbursement arrangement as that term is defined under IRS Notice and a medical reimbursement plan under Sections 105 and 106 of the Internal Revenue Code of 1986, as amended. The Exchange HRA Plan will be interpreted at all times in a manner consistent with such intent ARTICLE I ADOPTION AGREEMENT 1.1 Name of Plan: State of Nevada Public Employees Benefits Program Medicare Exchange Health Reimbursement Arrangement Plan (Exchange HRA Plan) 1.2 Plan Sponsor: State of Nevada Public Employees Benefits Program (PEBP) Contact: Quality Control Officer Address: 901 South Stewart Street, Suite 1001 Carson City, NV Telephone Number: (775) or (800) Tax Identification Number: Plan Administrator: State of Nevada Public Employees Benefits Program (PEBP) 1.4 Plan Number: EXCHANGE HRA 1.5 Effective Date: July 1, Eligible Retiree: A retiree who: (a) is eligible to be covered under PEBP pursuant to: (1) Nevada Revised Statutes Chapter 287; (2) Nevada Administrative Code Chapter 287, and (3) The PEBP Master Plan Document.

5 (b) (c) is eligible for free Medicare Part A elects coverage through the Individual Market Medicare Exchange sponsored by PEBP. For complete eligibility information, see the PEBP Master Plan Document. 1.7 Dependent: A spouse or other dependent (as defined in Internal Revenue Code Section 152) of an Eligible Retiree. For complete eligibility information, see the PEBP Master Plan Document. 1.8 Medical Expense Exclusion: There are currently no excluded Medical Expenses. See Internal Revenue Service Publication 502 for a list of Eligible Medical Expenses. PEBP reserves the right to change this section at any time. 1.9 Benefit Credit: (a) The following monthly amount will be credited on behalf of Eligible Retirees: (1) For Eligible Retirees who retired prior to January 1, 1994, the dollar amount is equal to the base amount (as determined by the Legislature each Legislative Session) multiplied by 15. (2) Except as otherwise provided in paragraph (3) below, for Eligible Retirees who retired on or after January 1, 1994, the dollar amount is equal to the base amount (as determined by the Legislature each Legislative Session) multiplied by the years of service credit (calculated pursuant to NAC ) up to a maximum of 20 years of service. (3) Retirees who were hired by their last employer on or after January 1, 2010, who subsequently retired and who: (i) (ii) Have less than 15 years of service credit (calculated pursuant to NAC ), or Were not continuously covered by PEPB since their retirement, are not eligible for any Benefit Credit. (b) No amount will be credited for dependents Insurance Coverage Exception: None. An Eligible Retiree must obtain an individual health insurance policy through the PEBP sponsored Individual Market Medicare Exchange, even if an Eligible Retiree has health coverage under TRICARE or under a policy or plan provided by his or her Spouse s employer. If 2

6 an otherwise Eligible Retiree resides outside the United States, the Eligible Retiree will not be considered an Eligible Retiree Account Structure: A separate Exchange HRA Account will be established for each Eligible Retiree within a single family Timing of Benefit Credit: Benefit Credit specified in Section 1.9 will be credited to Exchange HRA Accounts on the first business day of each calendar month Carryover of Accounts. Credits remaining in an Exchange HRA Account at the end of a Plan Year (after the expiration of the claims run-out period) shall be carried over to the following Plan Year to reimburse Eligible Retirees for Eligible Medical Expenses incurred during subsequent Plan Years, up to a limit to be determined by PEBP at a later date Death. Dependents shall NOT continue to receive Benefit Credits after the Eligible Retiree s death. ARTICLE II DEFINITION OF TERMS 2.1 Definitions. Whenever used in this Exchange HRA Plan document, the following terms shall have the meanings set forth below. (a) (b) (c) (d) Exchange HRA Account means the hypothetical account established for an Eligible Retiree to hold his or her Benefit Credits. Benefit Credit means the amount credited to an Eligible Retiree s Exchange HRA Account for the provision of benefits under the Exchange HRA Plan as provided in Section 4.2. Code means the Internal Revenue Code of 1986, as amended from time to time. Dependent means any Dependent who has satisfied the requirements of Section 1.7. (e) Effective Date means the date designated in Section 1.5. (f) (g) Eligible Retiree means any retiree who has satisfied the requirements of Section 1.6. Eligible Medical Expense means an expense incurred by an Eligible Retiree or by a Dependent in the Eligible Retiree s family, for medical care as defined in Code Section 213(d) and the rules, regulations and Internal Revenue Service interpretations there under, including premiums for health care insurance coverage. Eligible Medical Expenses shall not include expenses reimbursed or reimburseable under any private, 3

7 employer-provided, or public health care reimbursement or insurance arrangement or any amount claimed as a deduction on the federal income tax return of the Eligible Retiree or the Eligible Retiree s Dependent, or any expenses excluded in Section 1.8. In addition, and notwithstanding anything herein to the contrary, Eligible Medical Expenses shall include an expense incurred for a medicine or drug only if such medicine or drug is a prescribed drug (without regard to whether such medicine or drug is available without a prescription) or is insulin. Eligible Medical Expenses are incurred when the medical care is provided, not when the Eligible Retiree is formally billed, charged for, or pays the expenses. (h) (i) (j) (k) Exchange HRA Plan means the health reimbursement arrangement named in Section 1.1 and set forth herein, as may be amended from time to time. HIPAA means the Health Insurance Portability and Accountability Act of 1996, as amended from time to time. Individual Market Medicare Exchange means the health care exchange for Medicare eligible individuals operated by Extend Health, Inc., South Sterling View Drive, Suite A-1 South, South Jordan, UT (888) and its subcontractors. Plan Year means, the Plan Year as defined in the PEBP Master Plan Document. (l) PHI means protected health information as described in 45 C.F.R , and generally includes individually identifiable health information held by or on behalf of the Exchange HRA Plan. (m) (n) (o) Spouse means the legally married husband or wife of an Eligible Retiree as determined under federal law. Third Party Administrator means Extend Health, Inc., South Sterling View Drive, Suite A-1 South, South Jordan, UT 84095, (888) and its subcontractors. Years of Service means years of service as calculated pursuant to NAC and maintained in the eligibility records of PEBP. 2.2 Gender and Number. When used in this Exchange HRA Plan, the masculine shall include the feminine, the singular shall include the plural, and vice versa. ARTICLE III PARTICIPATION 3.1 Agreement to Participate. Participation in the Exchange HRA Plan shall begin on the date the Eligible Retiree: 4

8 (a) (b) (c) becomes eligible for coverage under Subchapter XVIII of Chapter 7 of Title 42 of the United States Code (Medicare Parts A and B); obtains an individual health insurance policy through the PEBP sponsored Individual Market Medicare Exchange identified in Section 2.1(j); and completes any enrollment form (which may be electronic) or any enrollment procedures as specified by PEBP. 3.2 Cessation of Participation. Participation in the Exchange HRA Plan will end: (a) (b) (c) (d) on the date the Eligible Retiree ceases to be an Eligible Retiree for any reason, including but not limited to: (1) enrollment in PEBP PPO or HMO coverage, if eligible; (2) enrollment in other group coverage that precludes enrollment in an individual Medicare plan; (3) employment as an active employee of the State of Nevada or a participating local government; (4) ineligibility for coverage under Subchapter XVIII of Chapter 7 of Title 42 of the United States Code (Medicare); or (5) death; on the effective date of any Exchange HRA Plan amendment that renders the Eligible Retiree ineligible to participate; on the effective date of termination of the Exchange HRA Plan; with respect to a Dependent, the date he or she ceases to be a Dependent for any reason, including but not limited to: (1) death; (2) divorce; (3) if the dependent is otherwise no longer considered a dependent pursuant to IRS Code 152; or (4) the cessation of participation of the Eligible Retiree. Reimbursement from the Eligible Retiree s Exchange HRA Account after termination of the Eligible Retiree s participation shall be governed by Section 5.3 or 5.5 as appropriate. ARTICLE IV FUNDING 4.1 Funding. The benefits provided herein shall be provided by PEBP out of its assets, and no assets shall be segregated or earmarked for the purpose of providing benefits hereunder, nor shall any person have any right, title or claim to 5

9 such assets prior to their payment hereunder. As such, each Exchange HRA Account established pursuant to the Exchange HRA Plan shall be a hypothetical account which merely reflects a bookkeeping concept and does not represent assets that are actually set aside for the exclusive purpose of providing benefits to the Eligible Retiree under the terms of the Exchange HRA Plan. In no event may any benefits under the Exchange HRA Plan be funded with Eligible Retiree contributions. 4.2 Benefit Credits. PEBP shall credit Exchange HRA Accounts of Eligible Retirees with the Benefit Credits specified in Section 1.9 at the time or times specified in Section The Benefit Credit to be made on behalf of an Eligible Retiree who is a Dependent shall be made to such Eligible Retiree s separate Exchange HRA Account. No earnings shall be credited at any time with respect to any Exchange HRA Account. ARTICLE V BENEFITS 5.1 Provision of Benefits. The Exchange HRA Plan will reimburse Eligible Retirees for Eligible Medical Expenses, up to the unused amount in the Eligible Retiree s Exchange HRA Account. An Eligible Retiree shall be entitled to reimbursement under this Exchange HRA Plan only for Eligible Medical Expenses incurred after he or she becomes an Eligible Retiree in the Exchange HRA Plan and before his or her participation has ceased. In no event shall any benefits under this Exchange HRA Plan be provided in the form of cash or any other taxable or nontaxable benefit other than reimbursement for Eligible Medical Expenses. 5.2 Amount of Reimbursement. At all times during a Plan Year, an Eligible Retiree shall be entitled to benefits under this Exchange HRA Plan for payment of Eligible Medical Expenses in an amount that does not exceed the balance of his or her Exchange HRA Account. Each reimbursement hereunder shall be a charge to such Exchange HRA Account available to pay Eligible Medical Expenses under the Exchange HRA Plan. 5.3 Expense Reimbursement Procedure. Reimbursement for Eligible Medical Expenses shall be made in accordance with this Section 5.3. (a) Timing: An Eligible Retiree desiring to receive reimbursement for Eligible Medical Expenses under this Exchange HRA Plan shall submit a written application to the Third Party Administrator. Upon loss of eligibility as provided in Section 3.2, coverage under the Exchange HRA Plan ceases and: (1) the Eligible Retiree shall receive no further Benefit Credits under the Exchange HRA Plan; (2) his or her Eligible Medical Expenses incurred after such date will not be reimbursed even if Benefit Credits remain in the Eligible Retiree s Exchange HRA Account; and 6

10 (3) the Eligible Retiree may submit claims for reimbursement for Eligible Medical Expenses incurred prior to his or her loss of eligibility, provided the Eligible Retiree files such claims within one hundred eighty (180) days of such loss of eligibility. (b) Claims Substantiation: PEBP or the Third Party Administrator may require the Eligible Retiree to furnish a bill, receipt, cancelled check or other written evidence or certification of payment or of obligation to pay Eligible Medical Expenses. The Third Party Administrator will reimburse the Eligible Retiree from PEBP assets for expenses that it determines are Eligible Medical Expenses up to the balance in the Eligible Retiree s Exchange HRA Account at such intervals as PEBP may deem appropriate (but not less frequently than monthly). PEBP, or the Third Party Administrator, reserves the right to verify to its satisfaction all claimed Eligible Medical Expenses prior to reimbursement. Each request for reimbursement shall include the following information: (1) the amount of the Eligible Medical Expense for which reimbursement is requested; (2) the date the Eligible Medical Expense was incurred; (3) a brief description and the purpose of the Eligible Medical Expense; (4) the name of the person for whom the Eligible Medical Expense was incurred and, if such person is not the Eligible Retiree requesting reimbursement, the relationship of the person to such Eligible Retiree; (5) the name of the person, organization or other provider to whom the Eligible Medical Expense was or is to be paid; (6) a statement that the Eligible Retiree has not been and will not be reimbursed for the Eligible Medical Expense by insurance or otherwise, and has not been allowed a deduction in a prior year (and will not claim a tax deduction) for such Eligible Medical Expense under Code Section 213; and (7) A written bill from an independent third party stating that the Eligible Medical Expense has been incurred and the amount of such expense and, at the discretion of PEBP, a receipt showing payment has been made. Expenses eligible for coverage under any medical, HMO, dental, or vision care plans in which the Eligible Retiree or his or her Dependents are enrolled must be submitted first to all appropriate claims administrators for such plans before submitting the expenses to the Third Party Administrator for reimbursement under the Exchange HRA Plan. An Eligible Retiree who is entitled to payment or reimbursement under a health care reimbursement account in a cafeteria plan under Code Section 125 must receive his or her maximum annual reimbursement under the 7

11 health care reimbursement account in the cafeteria plan before he or she is entitled to any reimbursement under this Exchange HRA Plan. Claims will be paid in the order in which they are filed with the Third Party Administrator and will be charged to the Exchange HRA Account of the Eligible Retiree who submits the claim. PEBP may establish such other rules as it deems desirable regarding the frequency of reimbursement of expenses, the minimum dollar amount that may be requested for reimbursement and the maximum amount available for reimbursement during any single month. (c) Claim Review Timing: The Third Party Administrator shall review such claim and respond within thirty (30) days after receiving the claim. If the Third Party Administrator determines that an extension is necessary due to matters beyond the control of the Exchange HRA Plan, the Third Party Administrator will notify the claimant within the initial thirty (30) day period that the Third Party Administrator needs up to an additional fifteen (15) days to review the claim. If such an extension is necessary because the claimant failed to provide the information necessary to evaluate the claim, the notice of extension will describe the information that the claimant will need to provide to the Third Party Administrator. The claimant will have no less than forty-five (45) days from the date he or she receives the notice to provide the requested information. The Third Party Administrator shall provide to every claimant who is denied a claim for benefits (in whole or in part) the following in a written or electronic notice: (1) the specific reason or reasons for the denial; (2) specific reference to pertinent plan provisions on which denial is based; (3) a description of any additional material or information necessary for the claimant to correct the claim and an explanation of why such material or information is necessary; (4) a copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the initial determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon in making the appeal determination and that a copy of such rule will be provided to claimant free of charge upon request; and (5) a description of the Exchange HRA Plan s appeal procedures and the time limits applicable to such procedures. (d) Claims Denied: Claims that are partially or wholly denied may be appealed to PEBP as provided in Section

12 5.4 Carryover of Accounts. To the extent an Eligible Retiree has a balance in his or her Exchange HRA Account at the end of a Plan Year, the balance shall be carried over to following Plan Years to the extent elected by PEBP in Section Death. In the event the Eligible Retiree dies, the Exchange HRA Account of the Eligible Retiree is immediately forfeited; provided, however, that his or her estate or representatives may submit claims for Eligible Medical Expenses incurred by the Eligible Retiree and his or her Dependents prior to the Eligible Retiree s death, as long as such claims are submitted no later than one-hundred eighty (180) days after the Eligible Retiree s death. 5.6 Nondiscrimination. PEBP may limit, reallocate or deny any benefit to any Eligible Retiree who was a highly compensated individual (as defined in Code Section 105(h)) to the extent necessary to avoid discrimination under Code Section 105(h). Any action of PEBP under this Section shall be carried out in a uniform and non-discriminatory manner. 5.7 Legal Provisions. (a) (b) Newborns and Mothers Health Protection Act of The Exchange HRA Plan may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than forty-eight (48) hours following a normal vaginal delivery, or less than ninety-six (96) hours following a cesarean section, or require that a provider obtain authorization from the Exchange HRA Plan or the insurance issuer for prescribing a length of stay not in excess of the above periods. Women s Health and Cancer Rights Act of To the extent the Exchange HRA Plan provides benefits with respect to mastectomy, it will provide, in the case of an individual who is receiving benefits in connection with a mastectomy and who elects reconstruction in connection with such mastectomy, coverage for all stages of reconstruction of the breast on which a mastectomy was performed, surgery and reconstruction of the other breast to provide a symmetrical appearance, prostheses, and coverage of physical complications at all stages of the mastectomy, including lymphedemas. ARTICLE VI CONTINUATION COVERAGE 6.1 Continuation Coverage. The Exchange HRA Plan provides no Benefit Credits for Dependents. Therefore, there are no continuation rights for Dependents under this Exchange HRA Plan. However, dependents who are covered under the PEBP PPO, HMO or Individual Market Medicare Exchange may continue that medical coverage following certain qualifying events as defined in the COBRA 9

13 Continuation of Medical Coverage section of the PEBP Master Plan Document as long as any required monthly premium is paid when due or during the applicable grace period. 6.2 Notices. The Eligible Retiree is responsible for providing the proper notice of qualifying events to PEBP as required by the PEBP Master Plan Document. 6.3 Discontinuation of Reimbursement. Eligible Retirees may not receive reimbursement for any Eligible Medical Expense incurred by a Dependent after that Dependent ceases to be a Dependent (as defined by Section 1.7) pursuant to Section 3.2(b), regardless of their right to continue other medical coverage as allowed by the PEBP Master Plan Document. ARTICLE VII ADMINISTRATION 7.1 Administration. PEBP shall be responsible for the performance of all reporting and disclosure obligations under the Public Health Services Act, and all other obligations required to be performed by PEBP under the Public Health Services Act or the Code, except such obligations and responsibilities as may be delegated under the Exchange HRA Plan to such person or entity as PEBP designates. PEBP shall be the designated agent for service of legal process with respect to the Exchange HRA Plan. 7.2 Duties of PEBP. (a) (b) (c) PEBP shall have the sole discretion and authority to control and manage the operation and administration of the Exchange HRA Plan. PEBP shall have complete discretion to interpret the provisions of the Exchange HRA Plan, make findings of fact, correct errors, supply omissions, and determine the benefits payable under this Exchange HRA Plan. All decisions and interpretations of PEBP made in good faith pursuant to the Exchange HRA Plan shall be final, conclusive and binding on all persons, subject only to the claims procedure below. PEBP shall have all other powers necessary or desirable to administer the Exchange HRA Plan, including, but not limited to, the following: (1) To prescribe procedures to be followed by Eligible Retirees in making elections under the Exchange HRA Plan and in filing claims under the Exchange HRA Plan; (2) To prepare and distribute information explaining the Exchange HRA Plan to Eligible Retirees; 10

14 7.3 Delegation of Duties. (3) To receive from Eligible Retirees and Dependents such information as shall be necessary for the proper administration of the Exchange HRA Plan; (4) To keep records of elections, claims, and disbursements for claims under the Exchange HRA Plan, and any other information required by the Public Health Services Act or the Code; (5) To appoint individuals or committees to assist in the administration of the Exchange HRA Plan and to engage any other agents as it deems advisable; (6) To promulgate election forms and claims forms to be used by Eligible Retirees, which may be electronic in nature; (7) To determine and enforce any limits on benefit elections hereunder; and (8) To correct errors and make equitable adjustments for mistakes made in the administration of the Exchange HRA Plan, specifically, and without limitation, to recover erroneous overpayments made by the Exchange HRA Plan to an Eligible Retiree or Dependent, in whatever manner PEBP deems appropriate, including suspensions or recoupment of, or offsets against, future payments due that Eligible Retiree or Dependent. (a) (b) PEBP shall have the authority to delegate all or any part of its responsibilities under the Exchange HRA Plan to one or more of its employees or other associated entities, and in the same manner to revoke any such delegation of responsibility. Any action of the delegate in the exercise of such delegated responsibilities shall have the same force and effect for all purposes as if such action had been taken by PEBP. The delegate shall periodically report to PEBP concerning the discharge of the delegated responsibilities. PEBP may employ such legal counsel, accountants, consultants, actuaries, and other agents as it shall deem advisable. The compensation of such legal counsel, accountants, consultants, actuaries and other agents and any other expenses incurred by PEBP in the administration or management of the Exchange HRA Plan or in furtherance of its duties shall be paid by PEBP. 7.4 Claims Procedure. (a) Within one hundred and eighty (180) days of receipt by a claimant of a notice under Section 5.3 denying a claim in whole or in part, the claimant or his or her duly authorized representative may request in writing a full and fair review of the claim by the Third Party Administrator. In connection with such review, the claimant or his or her duly authorized representative may, upon request and free of charge, have reasonable 11

15 access to, and copies of, all documents, records and other information relevant to the claim for benefits, and may submit issues and comments in writing. The Third Party Administrator shall make a decision promptly, but not later than sixty (60) days after the Third Party Administrator s receipt of a request for review. The decision on review shall be in writing, in a manner calculated to be understood by the claimant, and shall include: (b) (1) specific reasons for the decision; (2) specific references to the pertinent plan provisions on which the decision is based; (3) a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits; (4) a copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the initial determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon in making the appeal determination and that a copy of such rule will be provided to claimant free of charge upon request; and (5) a statement of the claimant s right to appeal any adverse benefit determination on review to PEBP, and, if necessary, to an external Independent Review Organization in accordance with Nevada Revised Statutes 695G.200 to 695G.310, inclusive, as amended by the 2011 Legislature. An adverse benefit determination on review may be appealed to PEBP within sixty (60) days after receipt of the adverse benefit determination from the Third Party Administrator. PEBP shall make a decision promptly, but not later than sixty (60) days after PEBP s receipt of an appeal. The decision of PEBP shall be in writing, in a manner calculated to be understood by the claimant, and shall include: (1) specific reasons for the decision; (2) specific references to the pertinent plan provisions on which the decision is based; (3) a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits; (4) a copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the initial determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon in making the appeal determination and that a copy of such rule will be provided to claimant free of charge upon request; and 12

16 (c) (5) a statement of the claimant s right to appeal any adverse benefit determination to an external Independent Review Organization in accordance with Nevada Revised Statutes 695G.200 to 695G.310, inclusive, as amended by the 2011 Legislature. The claimant may request an external review of an adverse benefit determination to an Independent Review Organization. Within four (4) months of receipt of the denial of the appeal by PEBP, the claimant must notify, in writing, the Nevada Office for Consumer Health Assistance pursuant to the provisions of Nevada Revised Statutes 695G.241 to 695G.310, inclusive, as amended by the 2011 Legislature. If the claimant requests an external review, the Independent Review Organization will be limited to the facts, evidence and issues presented during the claims procedure set forth above. The appeal process described herein must be exhausted before a claimant can pursue an external review. Facts and evidence that become known after having exhausted the appeals procedure may be submitted for reconsideration of the appeal in accordance with the time limits established above. Issues not raised during the appeal will be deemed waived. 7.5 Nondiscriminatory Operation. All rules, decisions, interpretations and designations by PEBP under the Exchange HRA Plan shall be made in a nondiscriminatory manner, and persons similarly situated shall be treated alike. ARTICLE VIII HIPAA 8.1 Purpose. This Article permits the Exchange HRA Plan to disclose PHI to PEBP to the extent that such PHI is necessary for PEPB to carry out its administrative functions related to the Exchange HRA Plan. This Article reflects the requirements set forth in 45 C.F.R (f) of HIPAA and the related regulations promulgated by the U.S. Department of Health and Human Services. Any term used in this Article VIII shall have the meaning set forth in HIPAA and guidance issued thereunder. 8.2 HIPAA Privacy Compliance. (a) Disclosures to PEBP. In accordance with HIPAA, the Exchange HRA Plan may disclose summary health information to PEBP as requested by PEBP to allow it to modify, amend or terminate the Exchange HRA Plan, or obtain premium bids from insurers to provide health insurance coverage under the Exchange HRA Plan. The Exchange HRA Plan may disclose to PEBP information on whether an individual is participating or enrolled in the Exchange HRA Plan. In addition, the Exchange HRA Plan may disclose protected health information to PEBP as necessary to allow PEBP to perform plan administration functions, as used within the meaning of the HIPAA privacy regulations, including the following functions: 13

17 (1) Collection of individual premiums or contributions; (2) Conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, contacting of health care providers and patients with information about treatment alternatives, and related functions; (3) Reviewing health plan performance; (4) Activities relating to obtaining or renewing health insurance or determining premium pricing for such benefits, or placing a contract for reinsurance of risk relating to such claims; (5) Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs; (6) Business planning and development of the Exchange HRA Plan, such as conducting cost-management and planning-related analyses, including formulary development and administration, development or improvement of methods of payment or coverage policies; (7) Business management and general administrative activities of the Exchange HRA Plan; (8) Determination of eligibility or coverage (including coordination of benefits or the determination of cost sharing amounts), and adjudication or subrogation of benefit claims; (9) Billing, claims management, collection activities, obtaining payment under a stop-loss contract, and related health care data processing; (10) Review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care or justification of charges; (11) Utilization review activities; (12) Disclosure to consumer reporting agencies of any of the following protected health information relating to collection of premiums or reimbursement: (A) (B) (C) (D) (E) (F) Name and address; Date of birth; Social security number; Payment history; Account number; and Name and address of the health care provider and/or health plan. 14

18 (b) (c) (13) Risk adjusting amounts due to enrollee health status and demographic characteristics. Access to Medical Information. The following employees or individuals under the control of PEBP shall have access to the Exchange HRA Plan s protected health information to be used solely for the purposes described above: (1) Employees of PEBP; and (2) Such other classes of individuals identified by the Exchange HRA Plan s Privacy Officer as necessary for the Exchange HRA Plan s administration. PEBP Agreement to Restrictions. PEBP agrees to: (1) Not use or disclose protected health information other than as permitted or required by law or as specified above; (2) Not use or disclose the protected health information in any employment-related decisions or in connection with any other benefit or employee benefit plan; (3) Report any use or disclosure of protected health information that is inconsistent with the uses and disclosures permitted by law or specified above of which PEBP becomes aware; (4) Make protected health information accessible to the subject individual in accordance with 45 CFR ; (5) Allow the subject individuals to amend or correct their protected health information in accordance with 45 CFR ; (6) Make available the information to provide an accounting of its disclosures of protected health information in accordance with 45 CFR ; (7) Make its internal practices, books and records available to the Secretary of Health and Human Services for determining compliance; (8) Return or destroy the protected health information received, if feasible, after it is no longer needed for the original purpose and retain no copies of such information or if not feasible, restrict access and uses as required by 45 CFR (f)(2)(ii)(I); (9) Ensure that any agents, including a subcontractor, of PEBP to whom PEBP provides protected health information shall also agree to these same restrictions; (10) Restrict access to protected health information to those classes of employees or individuals identified above; and (11) Restrict the use of protected health information by those employees identified above for plan administration functions within the meaning at 45 CFR (a). 15

19 (d) Noncompliance Resolution. In the event of noncompliance with the above restrictions by a designated employee or other individual receiving protected health information on behalf of PEBP, the employee or other individual shall be subject to discipline in accordance with PEBP s disciplinary procedures. Complaints or issues of noncompliance by such persons shall be filed with the Exchange HRA Plan s Privacy Official. 8.3 HIPAA Security Compliance. (a) (b) PEBP Obligations. PEBP shall do the following: (1) Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic PHI that it creates, receives, maintains, or transmits on behalf of the Exchange HRA Plan; (2) Ensure that the adequate separation required by 45 CFR (f)(2)(iii) is supported by reasonable and appropriate security measures; (3) Ensure that any agent, including a subcontractor, to whom it provides electronic PHI agrees to implement reasonable and appropriate security measures to protect the information; (4) Report any security incident of which it becomes aware; (5) Make PEBP s internal practices, books, and records relating to security of electronic PHI received from the Exchange HRA Plan available to the Secretary of Health and Human Services (or any other officer or employee of the U.S. Department of Health and Human Services to whom the authority involved has been delegated) for purposes of determining compliance by the Exchange HRA Plan with the HIPAA security standards. Exclusions. The provisions of (a) apply to all disclosures of electronic PHI by the Exchange HRA Plan to PEBP except: (1) Disclosures of summary health information to PEBP as reasonably requested by PEBP to allow it to modify, amend or terminate the Exchange HRA Plan, or to obtain premium bids from insurers to provide health insurance coverage under the Exchange HRA Plan; (2) Disclosures of information on whether an individual is participating or enrolled in the Exchange HRA Plan; and (3) Disclosures of information authorized by an individual in accordance with 45 CFR

20 ARTICLE IX GENERAL PROVISIONS 9.1 Amendment and Termination. Although PEBP intends to maintain the Exchange HRA Plan for an indefinite period, PEBP reserves the right to amend, modify, or terminate this Exchange HRA Plan at any time, including but not limited to the right to modify persons eligible for participation, benefits paid by the Exchange HRA Plan, and the amount of Benefit Credits to be credited, and the right to reduce or eliminate existing Exchange HRA Accounts. Notwithstanding anything to the contrary contained in this Section 9.1 or elsewhere in the Exchange HRA Plan, PEBP shall have the authority to approve all technical, administrative, regulatory and compliance amendments to the Exchange HRA Plan, and any other amendments that will not increase the cost of the Exchange HRA Plan to PEBP, as PEBP shall deem necessary or appropriate. 9.2 Adoption by Affiliates. Any participating local government agrees to be bound by the terms of the Exchange HRA Plan, as amended from time to time in accordance with Section 9.1. Any local government who has not entered into an agreement with PEBP pursuant to Nevada Revised Statutes but whose retirees are participating pursuant to Nevada Revised Statute are considered to be participating local governments only for the purposes of those participating retirees. 9.3 PEBP Liability. Benefits under the Exchange HRA Plan are paid by PEBP out of its assets. Specifically, and notwithstanding anything herein to the contrary, PEBP shall be solely responsible for the payment of benefits to such Eligible Retiree and his or her family members under this Exchange HRA Plan. PEBP shall have no liability with respect to the payment of any benefits to any person not eligible for participation in the Exchange HRA Plan. PEBP will be responsible for collecting amounts due from local government entities whose retirees are participating in the Exchange HRA Plan pursuant to Nevada Revised Statutes Alienation of Benefits. No benefit under this Exchange HRA Plan may be voluntarily or involuntarily assigned or alienated and any attempt to do so shall be void and unenforceable. 9.5 Facility of Payment. If PEBP deems any person incapable of receiving benefits to which he or she is entitled by reason of minority, illness, infirmity, or other incapacity, it may direct that payment be made directly for the benefit of such person or to any person selected by PEBP to disburse it, whose receipt shall be complete acquittance therefor. Such payments shall, to the extent thereof, discharge all liability of PEBP. 9.6 Lost Distributees. Any benefit payable hereunder shall be deemed forfeited if, after reasonable efforts, PEBP is unable to locate the Eligible Retiree to whom payment is due. 17

21 9.7 Status of Benefits. PEBP makes no commitment or guarantee that any amounts paid to or for the benefit of an Eligible Retiree under this Exchange HRA Plan will be excludable from the Eligible Retiree s gross income for federal, state, or local income tax purposes. It shall be the obligation of each Eligible Retiree to determine whether each payment under this Exchange HRA Plan is excludable from the Eligible Retiree s gross income for federal, state, and local income tax purposes and to notify PEBP if the Eligible Retiree has any reason to believe that such payment is not so excludable. Any Eligible Retiree, by accepting a benefit under this Exchange HRA Plan, agrees to be liable for any tax that may be imposed with respect to those benefits, plus any interest as may be imposed. 9.8 Applicable Law. The Exchange HRA Plan shall be construed and enforced according to the laws of the state of Nevada, to the extent not preempted by any Federal law. 9.9 Capitalized Terms. Capitalized terms shall have the meaning set forth in Article II Severability. If any provision of this Exchange HRA Plan shall be held invalid or unenforceable, such invalidity or unenforceability shall not affect any other provision, and this Exchange HRA Plan shall be construed and enforced as if such provision had not been included. Executed this day of,. Exchange HRA Plan Sponsor: By: Title: \V-7 18