Southwestern

Engaging Minds, Transforming Lives

University Policies


Benefits Continuation (COBRA and HIPAA)

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985, as amended)

A federal law (Public Law 99-272, Title X) known as COBRA, (Consolidated Omnibus Budget Reconciliation Act of 1985 as amended) requires that most employers sponsoring group health plan(s) offer employees and their families the opportunity for a temporary extension of coverage (called “continuation coverage”) at group rates in certain instances where coverage under the plan(s) would otherwise end. This notice is intended to inform you, in a summary fashion on your rights and obligations under the continuation coverage provisions of the law. This summary of rights should be reviewed by both you and your spouse (if applicable), retained with other benefit documents, and referred to in the event that any action as required on your part.

If you are an employee of Southwestern University, covered by its group health plan(s), you have a right to choose this continuation coverage if you lose your group health plan(s) coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part).

If you are the covered spouse of an employee, you have the right to choose continuation coverage for yourself if you lose coverage for any of the following four reasons:

  1. the death of the employee;
  2. the termination of the employee’s employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment;
  3. divorce or legal separation from the employee; or
  4. the employee becomes entitled to Medicare.

In the case of a covered dependent child of an employee, he or she has the right to continuation coverage if group health plan(s) coverage is lost for any of the following five reasons: 

  1. the death of the employee;
  2. the termination of the employee’s employment (for reasons other than gross misconduct) or a reduction in the employee’s hours of employment;
  3. divorce or legal separation from the employee;
  4. the employee becomes entitled to Medicare; or
  5. the dependent ceases to be a “Dependent Child” under the terms of the group health plan(s).

You also have the right to elect continuation coverage if you are covered under the plan(s) as a retiree or spouse or child of a retiree, and lose coverage within one year before or after the commencement of proceedings under Title 11 (bankruptcy), United States Code. Under the law, the employee or a family member has the responsibility to inform Southwestern University of a divorce, legal separation, or a child losing dependent status under the plan. This notification must be made within 60 days of the date of the qualifying event, which would cause a loss of coverage.

The notice must be in writing, and should be sent to:

Southwestern University
Human Resources Department
Benefits Coordinator
P.O. Box 770
Georgetown, TX 78627-0770
(512) 863-1807

When Southwestern University is notified that one of these events has happened, it will in turn notify you that you have the right to choose continuation coverage. Under the law, you have 60 days from the later of the date you would lose coverage or from the date of the notice to elect continuation coverage. If and when you make the election, coverage will become effective the day after coverage would otherwise be terminated.

If you do not choose continuation coverage, your group health plan(s) coverage will terminate in accordance with the provisions outlined in your benefits handbook or other applicable plan documents.

If you choose continuation coverage, your coverage will be identical to the coverage provided under the plan(s) to similarly situated employees or family members. The law requires that you be afforded to the opportunity to maintain continuation coverage for three years unless you lost group health plan(s) coverage because of a termination of employment or reduction in hours. In that case the required continuation coverage period is 18 months (an extension to 29 months is available under certain circumstances to disable person*). However the law also provides that your continuation coverage may be terminated for any of the following reasons:

1. the employer/former employer no longer provides group health plan(s) coverage to any of its employees;
2. the premium for your continuation coverage is not paid in a timely manner;
3. you first become, after electing COBRA, covered under any other group health plan(s) (as an employee or otherwise) which does not contain any exclusion or limitation with respect to any pre-existing condition;
4. you first become, after electing COBRA, entitled to Medicare.

*Note: A qualified beneficiary who is determined under Title II or XVI of the Social Security Act, to have been disabled as of the date of a termination of employment or reduction in hours, or within 60 days of COBRA coverage, may be eligible to continue coverage for an additional 11 months (29 months total). You must notify the employer within 60 days of the determination of disability by the Social Security Administration and prior to the end of the 18-month continuation period. The employer can charge up to 150% of the applicable premium during the 11-month extension. The disabled individual must notify the employer within 30 days of any final determination that he or she is no longer disabled. If the coverage is extended to a total of 29 months, extended coverage will cease upon a final determination that the Qualified Beneficiary is no longer disabled.

You do not have to show that you are insurable to choose continuation coverage. However, you will have to pay the group rate premium plus a 2% administrative fee for your continuation coverage. The law also requires that, at the end of the 18-month, 29-month, or 36-month continuation coverage period, you must be allowed to enroll in an individual conversion health plan provided under the current group health plan(s), if the plan provides a conversion privilege.

If you have any questions about this, please contact the person or office shown below. Also, if you have had a change in marital status, or you, your spouse, or any eligible covered dependent have had an address change, please notify in writing, the person or office shown below:

Southwestern University
Human Resources Department
Benefits Coordinator
P.O. Box 770
Georgetown, TX 78627-0770
(512) 863-1807

HIPAA NOTICE

In 1996 Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA impacts group health plans by improving the availability and portability of health coverage. HIPAA also requires that group health plan participants be given the following notices.

Notice of Enrollment Rights - If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Notice of Pre-existing Condition Exclusion - Under HIPAA, a “pre-existing condition” is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the six month period ending on the enrollment date in a health plan.

Your plan may exclude a pre-existing condition. If so, the pre-existing condition exclusion waiting period will not exceed 12 months beginning on the enrollment date. (For a late enrollee, the maximum waiting period is 18 months from the date coverage begins.) A pre-existing condition exclusion is inapplicable to a pregnancy or to a newborn child or adopted child under age 18 who becomes covered within 30 days of birth or adoption. A genetic condition without advice, care, or treatment is not a pre-existing condition.

If your plan contains a pre-existing condition exclusion, the existence of a pre-existing condition will be determined using information obtained relating to an individual’s health status before his or her enrollment date.

The pre-existing condition waiting period is reduced by any creditable coverage (prior coverage under various plans including, but not limited to, group health plans, individual health policies, Medicare, and Medicaid). You may obtain a certificate of creditable coverage from a prior plan sponsor or health insurance issuer. Should you disagree with the length of creditable coverage determined by your current plan, you have the right to appeal that determination and provide evidence of creditable coverage.

You should read and consult your schedule of benefits to see if your health plan contains a pre-existing condition exclusion.

HIPAA (The Health Insurance Portability and Accountability Act of 1996)

Notice of Health Information Privacy Practices – This notice describes the HIPAA requirement that health plans notify plan participants and beneficiaries about its policies and practices to protect the confidentially of their health information.

Background: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires health plans to notify plan participants and beneficiaries about its policies and practices to protect the confidentiality of their health information. This document is intended to satisfy HIPAA’s notice requirement with respect to all health information created, received or maintained by the Southwestern University Employee Health Plan, (the “Plan”) as sponsored by Southwestern University.

The Plan needs to create, receive, and maintain records that contain health information about you to administer the Plan and provide you with health care benefits. This notice describes the Plan’s health information privacy policy with respect to your Medical, Prescription Drug, and Health Care Flexible Spending Arrangement (FSA) benefits. The notice tells you the ways the Plan may use and disclose health information about you, describes your rights, and the obligations the Plan has regarding the use and disclosure of your health information. However, it does not address the health information policies or practices of your health care providers.

Southwestern University’s Pledge Regarding Health Information Privacy

The privacy policy and practices of the Plan protects confidential health information that identifies you or could be used to identify you, and relates to a physical or mental health condition or the payment of your health care expenses. This individually identifiable health information is known as “protected health information” (PHI). Your PHI will not be used or disclosed without a written authorization from you, except as described in this notice or as otherwise permitted by federal and state health information privacy laws.

Privacy Obligations of the Plan

The Plan is required by law to:

  • Make sure that health information that identifies you is kept private;
  • Give you this notice of the Plan’s legal duties and privacy practices with respect to health information about you; and
  • Follow the terms of the notice that is currently in effect.

How the Plan May Use and Disclose Health Information About You

The following are the different ways the Plan may use and disclose your PHI:

  • For Treatment. The Plan may disclose your PHI to a health care provider who renders treatment on your behalf. For example, if you are unable to provide your medical history as the result of an accident, the Plan may advise an emergency room physician about the types of prescription drugs you currently take.
  • For Payment. The Plan may use and disclose your PHI so claims for health care treatment, services, and supplies you receive from health care providers may be paid according to the Plan’s terms. For example, the Plan may receive and maintain information about surgery you received to enable the Plan to process a hospital’s claim for reimbursement of surgical expenses incurred on your behalf.
  • For Health Care Operations. The Plan may use and disclose your PHI to enable it to operate or operate more efficiently or make certain all of the Plan’s participants receive their health benefits. For example, the Plan may use your PHI for case management or to perform population-based studies designed to reduce health care costs. In addition, the Plan may use or disclose your PHI to conduct compliance reviews, audits, actuarial studies, and/or for fraud and abuse detection. The Plan may also combine health information about many Plan participants and disclose it to the University in summary fashion so it can decide what coverages the Plan should provide. The Plan may remove information that identifies you from health information disclosed to the University so it may be used without the University learning who the specific participants are.
  • To the University. The Plan may disclose your PHI to designated University personnel so they can carry out their Plan-related administrative functions, including the uses and disclosures described in this notice. Such disclosures will be made only to the University’s Associate Vice President for Human Resources (“the Plan Administrator”) and/or the members of the University’s Human Resources Department. These individuals will protect the privacy of your health information and ensure it is used only as described in this notice or as permitted by law. Unless authorized by you in writing, your health information: (1) may not be disclosed by the Plan to any other University employee or department; and (2) will not be used by the University for any employment-related actions and decisions, or in connection with any other employee benefit plan sponsored by the University.
  • To a Business Associate. Certain services are provided to the Plan by third party administrators known as “business associates.” For example, the Plan may input information about your health care treatment into an electronic claims processing system maintained by the Plan’s business associate so your claim may be paid. In so doing, the Plan will disclose your PHI to its business associate so it can perform its claims payment function. However, the Plan will require its business associates, through contract, to appropriately safeguard your health information.
  • Treatment Alternatives. The Plan may use and disclose your PHI to tell you about possible treatment options or alternatives that may be of interest to you.
  • Health-Related Benefits and Services. The Plan may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.
  • Individual Involved in Your Care or Payment of Your Care. The Plan may disclose PHI to a close friend or family member involved in or who helps pay for your health care. The Plan may also advise a family member or close friend about your condition, your location (for example, that you are in the hospital) or death.
  • As Required By Law. The Plan will disclose your PHI when required to do so by federal, state or local law, including those that require the reporting of certain types of wounds or physical injuries.

Special Use and Disclosure Situations

The Plan may also use or disclose your PHI under the following circumstances:

  • Lawsuits and Disputes. If you become involved in a lawsuit or other legal action, the Plan may disclose your PHI in response to a court or administrative order, a subpoena, warrant, discovery request, or other lawful due process.
  • Law Enforcement. The Plan may release your PHI if asked to do so by a law enforcement official, for example, to identify or locate a suspect, material witness, or missing person or to report a crime, the crime’s location or victims, or the identity, description or location of the person who committed the crime.
  • Workers’ Compensation. The Plan may disclose your PHI to the extent authorized by and to the extent necessary to comply with workers’ compensation laws or other similar programs.
  • Military and Veterans. If you are or become a member of the U.S. armed forces, the Plan may release medical information about you as deemed necessary by military command authorities.
  • To Avert Serious Threat to Health or Safety. The Plan may use and disclose your PHI when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person.
  • Public Health Risks. The Plan may disclose health information about you for public health activities. These activities include preventing or controlling disease, injury or disability; reporting births and deaths; reporting child abuse or neglect; or to report reactions to medication or problems with medical products or to notify people of recalls of products they have been using.
  • Health Oversight Activities. The Plan may disclose your PHI to a health oversight agency for audits, investigations, inspections, and licensure necessary for the government to monitor the health care system and government programs.
  • Research. Under certain circumstances, the Plan may use and disclose your PHI for medical research purposes.
  • National Security, Intelligence Activities, and Protective Services. The Plan may release your PHI to authorized federal officials: (1) for intelligence, counterintelligence, and other national security activities authorized by law; and (2) to enable them to provide protection to the members of the U.S. government, or foreign heads of state or to conduct special investigations.
  • Organ and Tissue Donation. If you are an organ donor, the Plan may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation.
  • Coroners, Medical Examiners, and Funeral Directors. The Plan may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. The Plan may also release your PHI to a funeral director, as necessary, to carry out his/her duty.

Your Rights Regarding Health Information About You

Your rights regarding the health information the Plan maintains about you are as follows:

  • Right to Inspect and Copy. You have the right to inspect and copy your PHI. This includes information about your plan eligibility, claim and appeal records, and billing records, but does not include psychotherapy notes.

To inspect and copy health information maintained by the Plan, submit your request in writing to the Plan Administrator. The Plan may charge a fee for the cost of copying and/or mailing your request. In limited circumstances, the Plan may deny your request to inspect and copy your PHI. Generally, if you are denied access to health information, you may request a review of the denial.

  • Right to Amend. If you feel that health information the Plan has about you is incorrect or incomplete, you may ask the Plan to amend it. You have the right to request an amendment for as long as the information is kept by or for the Plan.

To request an amendment, send a detailed request in writing to the Plan Administrator. You must provide the reason(s) to support your request. The Plan may deny your request if you ask the Plan to amend health information that was: not created by the Plan; not part of the health information kept by or for the Plan; not information that you would be permitted to inspect and copy; or accurate and complete.

  • Right to An Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of disclosures of your PHI that the Plan has made to others, except for those necessary to carry out health care treatment, payment or operations; disclosures made to you; or in certain other situations.

To request an accounting of disclosures, submit your request in writing to the Plan Administrator. Your request must state a time period, which may not be longer than six years prior to the date the accounting was requested.

  • Right to Request Restrictions. You have the right to request a restriction on the health information the Plan uses or disclosures about you for treatment, payment or health care operations. You also have the right to request a limit on the health information the Plan discloses about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that the Plan not use or disclose information about a surgery you had.

To request restrictions, make your request in writing to the Plan Administrator. You must advise us: (1) what information you want to limit; (2) whether you want to limit the Plan’s use, disclosure or both; and (3) to whom you want the limit(s) to apply.

Note: The Plan is not required to agree to your request.

  • Right to Request Confidential Communications. You have the right to request that the Plan communicate with you about health matters in a certain way or at a certain 1ocation. For example, you can ask that the Plan send your explanation of benefits (EOB) forms about your benefit claims to a specified address.

To request confidential communications, make your request in writing to the Plan Administrator. The Plan will make attempt to accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

  • Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may write to the Plan Administrator to request a written copy of this notice at any time.

Changes to This Notice

The Plan reserves the right to change this notice at any time and to make the revised or changed notice effective for health information the Plan already has about you, as well as any information the Plan receives in the future. The Plan will post a copy of the current notice in the University’s Human Resources Office at all times.

Complaints

If you believe your privacy rights under this policy have been violated, you may file a written complaint with the Plan Administrator at the address listed below. Alternatively, you may complain to the Secretary of the U.S. Department of Health and Human Services, generally, within 180 days of when the act or omission complained of occurred.

Note: You will not be penalized or retaliated against for filing a complaint.

Other Uses and Disclosures of Health Information

Other uses and disclosures of health information not covered by this notice or by the laws that apply to the Plan will be made only with your written authorization. If you authorize the Plan to use or disclose your PHI, you may revoke the authorization, in writing, at any time. If you revoke your authorization, the Plan will no longer use or disclosure your PHI for the reasons covered by your written authorization; however, the Plan will not reverse any uses or disclosures already made in reliance on your prior authorization.

Contact Information

If you have any questions about this notice, please contact:

Southwestern University Employee Health Plan Administrator
1001 E. University Avenue
Georgetown, TX 78626
(512) 863-1807

Posted 09/01/2015