Article 16: Nine Federal Laws You Should Know About >>

16.3 Health Insurance Portability and Accountability Act (HIPAA)

A federal law called the Health Insurance Portability and Accountability Act (HIPAA) requires this Administrative Office 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 allows a trust fund to not cover certain illnesses (for example, a heart condition) until the individual is covered under the trust fund for a designated period of time, typically six (6) to 12 months.

IMPORTANT: The medical plans (Kaiser Permanente HMO, UnitedHealthcare HMO, or the Blue Shield PPO Plan) offered through the Southern California IBEW-NECA Health Trust Fund do not contain any pre-existing condition exclusions. You become eligible for benefits under this Plan as explained in 4.1 Eligibility: When Coverage Begins without regard to any pre-existing medical conditions for which you may or may not have been treated prior to your effective date of coverage under this Plan. 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 (3) medical plans contains exclusion for experimental surgery. A detailed list of the exclusions for each of the plans is contained in the respective plan’s Evidence of Coverage document. Further information can be obtained by contacting the Administrative Office, Blue Shield PPO Plan or the HMO benefit provider.

A. HIPAA Privacy Rules

The Administrative Office maintains a hands-off policy for managing protected health information (“PHI”). PHI maintained by the Administrative Office of the Trust Fund is limited to names, ages, sex, marital status, eligibility and address information provided through the application and enrollment process. The law specifically limits the permissible use of this information absent your authorization. The Administrative Office does not receive nor maintain any identifiable medical claims information. All your medical claim information is maintained solely by the covered entities with whom the Trust Fund has entered into contracts and the third-party administrators with whom the Trust Fund has entered into contracts.

B. Information You Should Know as Required by HIPAA – Limitations on Benefit Changes in Existing Coverage During a Policy Year

In accord with applicable law except when an insurance policy is renewed you will receive at least 60 days advance written notice of any material reduction in covered services or benefits impacting the programs in which you are enrolled.
Certain benefit plans under the Southern California IBEW-NECA Health Trust Fund 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 or are responsible for administering certain benefits, as in the case of Coast Benefits, Inc.

Medical Plans
Blue Shield (PPO)
Kaiser Permanente (HMO)
UnitedHealthcare (HMO)

Dental Plans
DeltaCare USA (DHMO)
United Concordia (DHMO and PPO)

Health Reimbursement Arrangement
Coast Benefits, Inc.

Life Insurance
Blue Shield Life and
Health Insurance Company

Vision Insurance
Vision Service Plan

MAP
Optum is the health services division of UnitedHealth Group

Questions/Assistance
MedExpert Program

Each of the above benefit providers or third party administrator maintains an appeals procedure. This appeals procedure is explained in the Evidence of Coverage document or contract provided by each benefit provider or third party administrator. An example of an appeal under an HMO may be where you received emergency care outside the HMO network and the claim was denied by the HMO because they did not deem it an emergency. You can contact the benefit provider or third party administrator directly for information on their appeals procedure. Of course, the representative at MedExpert will also assist you if you have questions or need information. You can contact the MedExpert representative at (800) 999-1999.

You can contact the United States Department of Labor to seek assistance regarding your rights as provided by the Health Insurance Portability and Accountability Act (HIPAA), or other federal laws. 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