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, PacifiCare, or Indemnity Plan) offered through the Southern California IBEW-NECA Health Plan do not contain any pre-existing condition exclusions. When you become eligible for benefits under this Plan, as explained in the section titled "Eligibility & General Plan Provisions subtitled "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 three 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.

HIPAA Privacy Rules

HIPAA also gives you certain rights with respect to your health information, and requires that employee welfare plans, like the Southern California IBEW-NECA Active Health Plan, that provide 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, which was initially distributed to all participants as of April 14, 2003 (or when you enroll in the Plan, if you enroll after April 14, 2003) and which is available from the Fund Office.  The statement that follows is not intended and cannot be considered the Plan’s Notice of Privacy Practices.

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 Fund Manager, George Wallace.) 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 Fund Manager and other employees as designed by the Fund Manager.
  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.


• 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.

The Board of Trustees will return to the Plan or destroy all your protected health information received from the Plan when there is no longer a need for the information.  If it is not feasible for the Board of Trustees to return or destroy the protected health information, then the Trustees will limit their further use or disclosures of any of your protected health information that it cannot feasibly return or destroy.

Other Information You Should Know As Required By HIPAA

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 titled "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.

Certain benefit plans under the Southern California IBEW-NECA Active 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)
Dental Plans – CIGNA, DeltaCare USA, Safeguard, and United Concordia
Life Insurance – Metropolitan Life Insurance Co.

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.

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 East Colorado Boulevard, Suite 200
Pasadena, CA 91106
(626) 229-1000

Frequently Asked Questions About HIPAA

Q. If I change jobs, am I guaranteed the same benefits that I have under my current plan?
A. No. When a person transfers from one plan to another, the benefits the person receives will be those provided under the new plan. Coverage under the new plan can be different than the coverage under the former plan.

Q. Will I be covered immediately under my new employer’s plan?
A. Not necessarily. Plans may set a waiting period before individuals become eligible for benefits. HMOs may have an "affiliation period" during which an individual does not receive benefits and is not charged premiums. Affiliation periods run concurrently with any waiting period under a plan and may not last for more than 2 months (3 months for late enrollees) and are only allowed for HMOs that do not impose pre-existing condition exclusion periods.

Q. Does HIPAA require employers to offer health coverage or require plans to provide specific benefits?
A. No. The provision of health coverage by an employer is voluntary. HIPAA does not require specific benefits nor does it prohibit a plan from restricting the amount or nature of benefits for similarly situated individuals.

Q. What if my new employer does not provide health coverage?
A. There is no requirement for any employer to offer health insurance coverage. If your new employer does not offer health insurance, you may be eligible to continue coverage under this Plan’s COBRA continuation coverage.

Q. What if I cannot afford the premiums for group health coverage?
A. HIPAA does not limit premium rates, but it does prohibit plans and issuers from charging an individual more than similarly situated individuals in the same plan because of health status. Plans may offer premium discounts or rebates for participation in wellness programs. In addition, many states limit insurance premiums and HIPAA does not preempt state laws regulating the cost of insurance.

Q. Does HIPAA extend COBRA continuation coverage?
A. Generally no. However, HIPAA makes two changes to the length of the COBRA continuation coverage period.

Qualified beneficiaries who are determined to be disabled under the Social Security Act within the first 60 days of COBRA continuation coverage will be able to purchase an additional 11 months of coverage beyond the usual 18-month coverage period. This is a change from the previous law, which required that a qualified beneficiary be determined to be disabled at the time of the qualifying event to receive 29 months of COBRA continuation coverage. This extension of coverage is also available to non-disabled family members who are entitled to COBRA continuation coverage.

COBRA rules are also modified and clarified to ensure that children who are born or adopted during the continuation coverage period are treated as"qualified beneficiaries."