Information Required by the Health Insurance Portability & Accountability Act (HIPAA)

A federal law called the Health Insurance Portability and Accountability Act, referred to herein as HIPAA for short, requires this Plan to furnish you with certain information.

One purpose of HIPAA is to help families minimize the impact of pre-existing condition exclusions as they move from job to job. A pre-existing condition exclusion is where a medical plan may not cover certain illnesses (for example, a heart condition) until the individual is covered under the plan for a designated period of time, typically six to twelve months.

IMPORTANT: The medical plans (Kaiser Permanente or PacifiCare) offered through the Southern California IBEW-NECA Retiree Health Plan do not contain any pre-existing condition exclusions. When you become eligible for benefits under this Plan, as explained in the section entitled "Eligibility - When Coverage Begins", all covered benefits become effective on the date you become eligible for benefits under this Plan.

However, each medical plan does have benefit exclusions and limitations for designated illnesses and conditions.  For example, each of the four medical plans contains an exclusion for experimental surgery.  A summary of the exclusions for each of the plans is contained in this Summary Plan Description. Further information can be obtained by contacting the Administrative Office, or the HMO benefit provider. Also, refer to the Evidence of Coverage booklet provided to you by the HMO in which you are enrolled.

Certificate of Group Health Plan Coverage

When you lose eligibility under this Plan, you will be furnished with what is called Certificate of Group Health Plan Coverage. This certificate provides you with evidence of your prior health coverage with this Plan. You may need to furnish this certificate if you become eligible under a group health plan that excludes coverage for certain medical conditions before you enroll. This certificate may need to be provided if medical advice, diagnosis, care, or treatment was recommended or received for the condition within the six months prior to your enrollment in the new plan.

If you become covered under another group health plan, check with the Administrative Office to see if you need to provide this certificate. You may also need this certificate to buy, for yourself or your family, an insurance policy that does not exclude coverage for medical conditions that are present before you enroll.

Board of Trustees HIPAA Statement

HIPAA also gives you certain rights with respect to your health information, and requires that employee welfare plans, like the Southern California IBEW-NECA Retiree Health Plan that provides health benefits, protect the privacy of your personal health information.  A complete description of your rights under HIPAA will be found in the Plan’s Notice of Privacy Practices included in this section.

Each HMO maintains its own privacy policy.  A Participant who enrolls in an HMO will receive (upon enrollment) a copy of that HMO’s privacy policy.  A Participant may receive an advance copy of the HMO privacy policy by requesting a copy from the Administrative Office.

Since the Plan is required to keep your health information confidential, before the Plan can disclose any of your health information to the Board of Trustees, which acts as the sponsor of the Plan, the Trustees must also agree to keep your health information confidential.  In addition, the Trustees must agree to handle your health information in a way that enables the Plan to follow the rules in HIPAA.  The health information about you that the Board of Trustees receives from the Plan (except for any information that is received in connection with the death benefits) is referred to below as "protected health information". The Board of Trustees agrees to the following rules in connection with your protected health information:

• The Board of Trustees understands that the Plan will only disclose health information to the Board of Trustees for the Trustees’ use in plan administration functions.


• Unless it has your written permission, the Board of Trustees will only use or disclose that protected health information for that plan administration, or as otherwise permitted by this Summary Plan Description, or as required by law.


• The Board of Trustees will not disclose your protected health information to any of its agents or subcontractors unless the agents and subcontractors agree to handle your protected health information and keep it confidential to the same extent as is required of the Board of Trustees in this Summary Plan Description.


• The Board of Trustees will not use or disclose your protected health information for any employment-related actions or decisions, or with respect to any other pension or other benefit plan sponsored by the Board of Trustees without your specific written permission.


• The Board of Trustees will report to the Plan’s Privacy Officer (The designated privacy officer is the Administrative Corporation.) if the Trustees become aware of any use or disclosure of protected health information that is inconsistent with the provisions set forth in this Summary Plan Description.


• The Board of Trustees will allow you, through the Plan, to inspect and photocopy your protected health information, to the extent, and in the manner, required by HIPAA.


• The Board of Trustees will make available protected health information for amendment and incorporation of any such amendments to the extent, and in the manner required by HIPAA.


• The Board of Trustees will keep a written record of certain types of disclosures it may make of protected health information, so that it may make available the information required for the Plan to provide an accounting of certain types of disclosures of protected health information.


• The following categories of employees under the control of the Board of Trustees are the only employees who may obtain protected health information in the course of performing the duties of their job with or for the Board of Trustees who obtained such health information:


1. The Administrative Corporation and other employees as designed by the Administrative Corporation.
2. These employees will be permitted to have access to and use the protected health information only to perform the Plan administration functions that the Board of Trustees provides for the Plan.
3. The employees listed above will be subject to disciplinary action and sanctions for any use or disclosure of protected health information that violates the rules set forth in this Summary Plan Description.  If the Board of Trustees becomes aware of any such violations, the Board of Trustees will promptly report the violation to the Plan and will cooperate with the Plan to correct the violation, to impose appropriate sanctions, and to mitigate any harmful effects to the participants whose privacy has been violated.


• The Board of Trustees will make available to the Secretary of Health and Human Services its internal practices, books and records relating to the use and disclosure of protected health information received from the Plan in order to allow the Secretary to determine the Plan’s compliance with HIPAA.

Use & Disclosure of Protected Health Information

1. Use and disclosure of Protected Health Information (PHI): The Plan will use protected health information to the extent and in accordance with the uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Specifically, the Plan will use and disclose protected health information for purposes related to health care diagnosis and treatment, payment for health care and health care operations.

"Payment" includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibility for coverage and provisions of Plan benefits that relate to an individual to whom health care is provided.  These activities include, but are not limited to, the following:


1. Determination of eligibility, coverage, and cost sharing amounts (e.g. cost of a benefit, Plan maximums and co-payments as determined for an individual's claims),


2. Coordination of benefits,


3. Adjudication of health benefit claims (including appeals and other payment disputes),


4. Subrogation of health benefit claims,


5. Establishing employee or employer contributions,


6. Risk adjusting amounts due based on enrollee health status and demographic characteristics,


7. Billing, collection activities and related health care data processing,


8. Claims management and related health care data processing, including auditing payments, investigating and resolving payment disputes and responding to participant inquiries about payments,


9. Obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance),


10. Medical necessity reviews, or reviews of appropriateness of care or justification of charges,


11. Utilization review, including recertification, preauthorization, concurrent review and retrospective review,


12. Disclosure to consumer reporting agencies related to collection of premiums or reimbursement (the following PHI may be disclosed for payment purposes; name and address, date of birth, SSN, payment history, account number and name and address of provider and/or health Plan), and


13. Reimbursement to the Plan.

Health Care Operations include, but are not limited to, the following activities:


1. Quality Assessment,


2. Population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, disease management, contracting of health care providers and patients with information about treatment alternatives and related functions,


3. Rating provider and Plan performance, including accreditation, certification, licensing or credentialing activities,


4. Underwriting, premium rating, and other activities relating to the creation, renewal of replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care (including stop-loss insurance and excess of loss insurance),


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, such as conducting cost-management and planning-related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies,


7. Business management and general administrative activities of the entity, including, but not limited to:
   1. Management activities relating to implementation of and compliance with the requirements of HIPAA Administrative Simplification,
   
   
   2. Customer service, including the provision of data analyses for policyholders, Plan sponsors, or other customers,
   
   
   3. Resolution of internal grievances, and
   
   
   4. Due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the potential successor in interest is a covered entity or, following completion of the sale or transfer, will become a covered entity.


8. Compliance with and preparation of all documents as required by the Employee Retirement Income Security Act of 1974 (ERISA), including form 5500’s, SAR’s and other documents.


2. The Plan will use and disclose PHI as required by law and as permitted by authorization of the participant or beneficiary.  With an authorization, the Plan will disclose PHI to related pension plans, disability programs and Workers' Compensation insurers for purposes related to administration of these plans.


3. For purposes of this section the Board of Trustees is the Plan Sponsor.  The Plan will disclose PHI to the Plan Sponsor only upon receipt of a certification from the Plan Sponsor that this amendment has been duly adopted by the Board.

With respect to PHI, the Plan Sponsor agrees to:

1. Not use or further disclose the information other than as permitted or required by the Plan Document or as required by law,


2. Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such information,


3. Not use or disclose the information for employment-related actions and decisions unless authorized by the individual,


4. Not use or disclose the information in connection with any other benefit or employee benefit Plan of the Plan Sponsor unless authorized by the individual,


5. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware,


6. Make PHI available to the individual in accordance with the access requirements of HIPAA,


7. Make PHI available for amendment and incorporate any amendment to PHI in accordance with HIPAA,


8. Make available the information required to provide an accounting of disclosures,


9. Make internal practices, books, and records relating to the use and disclosure of PHI received from the group health Plan available to the Secretary of HHS for the purposes of determining compliance by the Plan with HIPAA, and


10. If feasible, return or destroy all PHI received from the Plan that the sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose of which disclosure was made.  If return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction feasible.


4. Adequate separation between the Plan and the Plan Sponsor must be maintained.  Therefore, in accordance with HIPAA, only the following entities, individuals or classes of employees may be given access to PHI:


1. Any entity providing administrative services in the Plan,


2. Staff designed by the entities providing administrative services to the Plan,


3. The Plan’s Trustees, providers, insurers, consultant, attorney and/or auditor but only to the extent necessary for those entities or individuals to provide necessary services to the Plan.


5. The persons described in Section D may only have access to and use and disclose PHI for Plan administration functions that the Plan Sponsor performs for the Plan.


6. If the persons described in Section D do not comply with this Plan Document, the Plan Sponsor shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions.


7. For purposes of complying with HIPAA privacy rules, this Plan is a "Hybrid entity" because it has both health plan and non-health plan functions.  The Plan designates that its health care components that are covered by the privacy rules include only health benefits and not other plan functions or benefits.

Other Information You Should Know As Required By HIPAA

1. HIPAA requires that Plan participants be notified of material reductions in health plan coverage within 60 days of the change.  Contained in this Summary Plan Description is a section entitled "Plan Amendment Procedures" which explains the notice you will receive if there is a material reduction in benefits.  This Plan will provide notice of such changes to Plan participants no less than 60 days prior to the effective date of such changes.
   


2. Certain benefit plans under the Southern California IBEW-NECA Retiree Health Plan have benefits guaranteed under contract between the Board of Trustees and the benefit provider. The following providers have guaranteed benefits by contract with the Board of Trustees.

   Medical Plans – Kaiser Permanente (HMO) and PacifiCare (HMO), Kaiser Senior Advantage and PacifiCare Secure Horizons
   
   Dental Plan – CIGNA (DMO), DeltaCare USA (DMO), Safeguard (DMO), United Concordia (DMO)
   
   Vision Plan – Vision Service Plan, Kaiser Permanente Vision Plan
   
   Each of the above benefit providers maintains an appeals procedure. This appeals procedure is explained in the Evidence of Coverage document provided by each benefit provider.  An example of an appeal under an HMO may be where you received emergency care outside the HMO and the claim was denied by the HMO because they did not deem it an emergency. You can contact the benefit provider directly for information on their appeals procedure.  Of course, the Administrative Office will also assist you if you have questions or need information.

3. You can contact the United States Department of Labor to seek assistance on your rights as provided by the Health Insurance Portability and Accountability Act (HIPAA). The office to contact is as follows:

   United States Department of Labor
   Employee Benefits Security Administration
   1055 E. Colorado Boulevard
   Suite 200 Pasadena, CA  91106
   (626) 229-1000