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Laws Affecting Benefits
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985
If you terminate your employment or reduce
your hours of employment, you will usually have the right to
temporarily continue your health and dental coverage through
Case. The remainder of this letter explains your specific legal
rights. This law requires that most employers sponsoring group
health plans offer employees and their families the opportunity
for a temporary extension of health and dental coverage (called
"COBRA coverage") at group rates in certain qualifying instances
where coverage under the plan would otherwise end. If you are
an employee of Case and are covered by one of the group health
and dental plans, you have a right to choose COBRA coverage
if you lose your group health 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 spouse of an employee covered by one of the
university's basic health plans, you have the right to choose
COBRA coverage for yourself if you lose group health coverage
due to any one of the following four qualifying events:
- The death of your spouse;
- A termination of your spouse's Case employment (for reasons
other than gross misconduct) or reduction in your spouse's
hours of employment that renders him/her ineligible to continue
group medical and dental coverage;
- Divorce or legal separation from your spouse; or
- Your spouse becomes entitled to Medicare.
If you are the dependent child of a former Case employee and
covered by a group health or dental plan sponsored by Case,
you have the right to choose COBRA coverage for yourself if
your group health and dental coverage stops due to any one of
the following five qualifying events.
- The death of a parent;
- A termination of your parent's Case employment (for reasons
other than gross misconduct) or reduction in your parent's
hours of employment with Case that renders him/her ineligible
to continue group medical and dental coverage;
- Parents' divorce or legal separation;
- A parent becomes entitled to Medicare; or
- The dependent child attains the age of 19 (age 23 if a full-time
student)
If you choose COBRA coverage, Case will provide the same coverage
which is being provided to all similarly situated employees
and family members. Under the law, the employee of a family
member has the responsibility to inform Benefits Administration
of a divorce, legal separation, or child losing dependent status
under one of the plans. The University must internally identify
the employee's death, termination of employment, reduction in
hours, or Medicare eligibility.
When Benefits Administration is advised that a qualifying event
has occurred, Benefits Administration will notify you that you
have the right to choose COBRA coverage. Under the law, you
have 60 days from the date you would lose coverage due to one
of the qualifying events described above to inform Benefits
Administration that you want COBRA coverage.
If you do not choose COBRA coverage, your group health insurance
coverage will end as of the date of the qualifying event. If
you do choose COBRA coverage, the university is required to
give you coverage which, as of the time coverage is being provided,
is identical to the coverage provided under the plan to similarly
situated employees of family members. The law requires that
you be afforded the opportunity to maintain coverage for up
to 36 months unless you lost group health coverage because of
a termination of employment or reduction in hours. In that case,
the required COBRA coverage period is 18 months. If you are
disabled at the time of the original qualifying event, you may
be eligible for a total of 29 months of COBRA coverage, provided
that a determination letter from the Social Security Administration
is presented as evidence before the 18-month COBRA coverage
period has expired. However, the law also provides that your
COBRA coverage may be cut short for any of the following five
reasons:
- The university no longer provides group health and dental
coverage to any of its employees;
- The premium for your COBRA coverage is not paid (payment
must be received no later than 30 days after it is due);
- You become covered under another group health plan as an
employee or otherwise;
- You become entitled to Medicare;
- You were divorced from a covered employee and subsequently
remarry and are covered under your new spouse's group health
plan.
You do not have to show that you are insurable to choose COBRA
coverage. You will be responsible for paying both the employer
and the employee's premiums to receive this coverage plus two
percent (2%) to cover administrative costs. The law also says
that, at the end of the 18-month or 36-month coverage period,
you must be allowed to enroll in an individual conversion health
plan provided by the particular carrier.
This law applies to any of the university health plans beginning
on June 1, 1987, under §10002(d) of COBRA as enacted April 7,
1986 (Public Law 99-272, Title X), and as amended. If you have
any questions about the law, please contact Case Western Reserve
University, Benefits Administration, 224 Crawford Hall, 10900
Euclid Avenue, Cleveland, Ohio 44106-7047. Also if you have
changed marital status or you or your spouse have changed addresses,
please notify Benefits Administration at the above address.
HIPAA and Privacy Practices on Protected Health Information
HIPPA Notice of Availability
Protected health information (PHI) means any information, transmitted
or maintained in any form or medium, which the Plan creates
or receives that relates to your physical or mental health,
the delivery of health care services to your or payment for
health care services and that identifies you or could be used
to identify you. We maintain your PHI in records we create of
claims submitted to or payments made by the Plan and related
information. This Notice applies to all of those records created,
received or maintained by the Plan.
The university is permitted to use and disclose your protected
health information (PHI) (1) to provide treatment to you, (2)
to be paid or request payment for our services, and (3) to conduct
health care operations. This section of this Notice discusses
each of these types of uses and disclosures of PHI.
- For Treatment. We may use PHI about you in connection with
health care treatment or services. We may disclose PHI to
doctors, nurses, hospitals, clinics, or other health care
providers who are involved in your care. For example, a doctor
treating you for a medical condition may need to know the
medications which have been prescribed for you, or the services
and items that have been provided to you. We may also share
PHI about you in order to coordinate health care services
and items that you may need.
- For Payment. We may use and disclose PHI about you to process
payments for the services and items that you receive from
health care providers. For example, we may need to share your
health information with a provider to verify the delivery
of services or items that you received so that the Plan can
pay the provider or reimburse you for the services or items.
- For Health Care Operations. We may use and disclose PHI
about you for health care operations. These uses and disclosures
are necessary to make sure you receive quality care. For example,
we may use PHI to review treatment and services and to evaluate
the performance of providers. We may also disclose information
to doctors, nurses, hospitals, clinics, and other health care
providers, for review and learning purposes. We may remove
information that identifies you from PHI used for such purposes
so others may use it to study health care and health care
delivery without learning the names of the specific individuals.
Listed below are a number of other ways that the Plan is permitted
or required to use or disclose PHI. This list is not exhaustive.
Therefore, not every use or disclosure in a category is listed.
- Individuals Involved in Your Care or Payment for Your Care.
We may release PHI about you to a friend or family member
who is involved in your medical care. We may also give information
to someone who helps pay for your care. In addition, we may
disclose PHI about you to a person or entity assisting in
an emergency so that your family can be notified about your
condition, status and location.
- As Required By Law. We will disclose PHI about you when
required to do so by federal, state, or local law.
- Public Health Risks. We may disclose PHI about you for public
health activities, including to prevent or control disease
or, when required by law, to notify public authorities concerning
cases of abuse or neglect.
- Health Oversight Activities. We may disclose PHI to a health
oversight agency for activities authorized by law. These oversight
activities include, for example, audits, investigations, inspections,
and licensure.
- Lawsuits and Disputes. If you are involved in a lawsuit
or dispute, we may disclose PHI about you in response to a
court or administrative order. We may also disclose PHI about
you in response to a subpoena, discovery request, or other
lawful process by someone else involved in the dispute, but
only if efforts have been made to tell you about the request
or to obtain an order protecting the information requested.
- Law Enforcement. We may release PHI if asked to do so by
a law enforcement official as permitted by law.
- Coroners and Medical Examiners. We may release PHI to a
coroner or medical examiner. This may be necessary, for example,
to identify a deceased person or determine the cause of death.
- Research. Under certain circumstances, we may use and disclose
PHI about you for research purposes. For example, we might
disclose PHI to be used in a research project involving the
effectiveness of certain treatment. In some cases, we might
disclose PHI for research purposes without your knowledge
or approval. However, such disclosures will be made only if
approved through a special process. This process evaluates
a proposed research project and its use of PHI, trying to
balance the research needs with an individual's need for privacy
of their PHI.
- To Avert a Serious Threat to Health or Safety. We may use
and disclose PHI about you when necessary to prevent a serious
threat to your health and safety or the health and safety
of the public or another person.
- Military and Veterans. If you are a member of the armed
forces, we may release PHI about you as required by military
command authorities.
- Health-Related Benefits and Services. We may use and disclose
PHI to tell you about health-related benefits or services
that may be of interest to you.
- Workers’ Compensation. We may release PHI about you for
workers’ compensation or similar programs. These programs
provide benefits for work-related injuries or illness.
- Fundraising. We may disclose PHI about you for fundraising
purposes. Any such disclosure of PHI will be limited in scope
and disclosed only to our business associates or to a charitable
organization which is obligated to act for the benefit of
Case. If you do not want Case to contact you about fundraising,
you must notify the Case Privacy Officer in writing. Further
information about disclosures for fundraising purposes may
be found in Case’s Policies and Procedures, “Fundraising.”
Other uses and disclosures will be made only upon your written
authorization. You have the right to revoke such authorization,
in writing, except where we have previously taken action in
reliance on your prior authorization or if the authorization
was a condition to obtaining insurance or health plan coverage
and applicable law provides the insurer or health plan with
the right to contest a claim under the policy.
When required to do, the Plan will disclose only the minimum
amount of PHI necessary to accomplish the intended purpose of
a use, disclosure or request for PHI.
Certain provisions of Ohio law may now, or in the future, impose
greater restrictions on uses and/or disclosures of PHI or otherwise
be more stringent than federal rules protecting the privacy
of PHI. If such provisions of Ohio law apply to a use or disclosure
of PHI or under other circumstances described in this Notice,
Case must comply with those provisions.
You have the following rights with respect to your PHI:
- Right to Inspect and Copy. You have the right to inspect
and copy your PHI maintained by the Plan. Generally, this
information includes health care and billing records. You
do not have a right of access to (1) psychotherapy notes;
(2) information prepared in anticipation of or for use in,
a civil, criminal, or administrative action; and (3) PHI maintained
by the Plan that is (a) subject to the Clinical Laboratory
Improvements Amendments (“CLIA”) of 1988, 42 U.S.C. 263a,
if access to the individual would be prohibited by law, or
(b) exempt from CLIA pursuant to 42 CFR 493.3(a)(2). Under
certain circumstances, you also do not have a right of access
to information created or obtained in the course of research
involving treatment or received from someone other than a
health care provider under a promise of confidentiality.
- To inspect and copy PHI maintained by the Plan, you must
submit your request in writing to Case’s Privacy Officer.
We may charge a fee for the costs of copying, mailing or other
supplies associated with you request. We may deny your request
to inspect and copy your PHI for the reasons set forth above
or under certain other limited circumstances. If you are denied
access to PHI other than for a reason stated above, you will
receive a written denial. You may request that the denial
be reviewed. Thereafter, a licensed health care provider chosen
by Case will review your request and the denial. The person
conducting the review will not be the person who originally
denied your request. We will comply with the outcome of the
review.
- Right to Request Amendment. You may ask us to amend the
PHI we have about you. You have the right to request an amendment
for so long as the information is kept by or for the Plan.
To request an amendment to your PHI, your request must be
made in writing and submitted to Case’s Privacy Officer. In
addition, you must provide a reason that supports your request.
We will generally make a decision regarding your request for
amendment no later than 60 days after receipt of your request.
However, if we are unable to act on the request within this
time, we may extend the time for 30 more days, but we will
provide you with a written notice of the reason for the delay
and the approximate time for completion. If we deny your requested
amendment, we will provide you with a written denial.
- We have the right to deny your request for an amendment
if it is not in writing or does not include a reason to support
the request. We are not required to agree to your request
if you ask us to amend PHI that: was not created by us, unless
the person or entity that created the information is no longer
available to make the amendment; is not part of the PHI kept
by or for the Plan; is not part of the PHI which you would
be permitted to inspect and copy; or is already accurate and
complete.
- Right to an Accounting of Disclosures. You have the right
to request an “accounting of disclosures.” This is a list
of certain disclosures of PHI we have made about you. We do
not have to list certain disclosures such those made for the
purposes of treatment, payment, or healthcare operations,
pursuant to a prior authorization by you or for certain law
enforcement purposes.
- To request this list or accounting of such disclosures,
your request must be submitted in writing to Case’s Privacy
Officer. Your request must also state a time period, which
may not be longer than six years and may not include dates
before April 14, 2003. Your request should also specify the
format of the list you prefer (i.e. on paper or electronically).
The first list you request within a twelve month period will
be free. For additional lists, we may charge you for the costs
of providing the list. We will notify you of the costs involved
and you may choose to withdraw or modify your request at that
time before any costs are incurred.
- Right to Request Restriction of Uses and Disclosures. You
have the right to request that we restrict the uses and disclosures
of PHI about you to carry out treatment, payment or health
care operations and/or to individuals involved in your care.
We cannot restrict disclosures required by law or requested
by the federal government to determine if we are meeting our
privacy protection obligations. We are not required to agree
to your request; however, if we do agree, we will comply with
your request unless the information is needed to provide you
emergency health care treatment. To request restrictions,
you must make your request in writing to Case’s Privacy Officer.
Your request must specify (1) what PHI you want to limit;
(2) whether you want to limit our use, disclosure or both;
and (3) to whom you want the limits to apply (i.e., disclosures
to your spouse). We may terminate our agreement to the restriction
if you orally agree to the termination and it is documented,
you request the termination in writing, or we inform you that
we are terminating our agreement with respect to any information
created or received after receipt of our notice.
- Right to Request Confidential Communications. You also have
the right to request that we communicate with you about health
care matters in a certain way or at a certain location. For
example, you can ask that we only contact you at work or by
mail. To request confidential communications, you must make
your request in writing to Case’s Privacy Officer. We will
not ask you the reason for your request. We will accommodate
all reasonable requests. You request must specify how or where
you wish to be contacted.
- Right to Receive Notice Electronically. You have the right
to a paper copy of this Notice. You may ask us to give you
a copy of this Notice at any time. Even if you have agreed
to receive this Notice electronically, you are still entitled
to a paper copy of this Notice. To obtain a paper copy of
this notice, please write to or call Case’s Privacy Officer.
The university reserves the right to change our privacy practices
that are described in this Notice. We reserve the right to make
the revised or changed privacy practices applicable to PHI we
already have about you as well as any information we receive
in the future. Prior to a material change to the uses or disclosures,
your rights, our legal duties, or other privacy practices stated
in this Notice, we will promptly revise the Notice. The Notice
will contain the effective date on the first page.
If you believe your privacy rights have been violated, you
may file a complaint with Case or with the Secretary of the
Department of Health and Human Services. To file a complaint
with Case, write to Case’s Privacy Officer, Case Western Reserve
University, 10900 Euclid Avenue, Cleveland, OH 44106-7048. All
complaints must be in writing. You will not be penalized or
retaliated against for filing a complaint.
Other uses and disclosures of PHI not covered by this Notice
or the laws that apply to us will be made only with your written
authorization. If you provide us permission to use or disclose
PHI about you, you may revoke that authorization, in writing,
at any time. If you revoke your authorization, we will no longer
use or disclose PHI about you for the reasons covered by your
written authorization. You understand that we are unable to
retract any disclosures we have already made with your authorization,
and that we are required to retain records of the Plan relating
to claims, coordination of benefits, payments by the Plan and
related matters.
Women’s Health and Cancer Rights Act of 1998
Also known as “Janet’s Law,” the WHCRA requires health care
benefit plans to provide certain coverage following a mastectomy.
The law also requires annual notification to all plan participants
and their covered beneficiaries. Case group health plans provide
coverage for mastectomies. As part of this coverage, the plans
also cover procedures necessary to effect reconstruction of
the breast on which the mastectomy was performed, as well as
the cost of prostheses (implants, special bras, etc.). Coverage
is also provided for physical complications of all stages of
mastectomy, including lymphedemas, as recommended by the attending
physician of any patient receiving plan benefits in connection
with the mastectomy. Health plans also cover any necessary surgery
and reconstruction of the breast on which a mastectomy was performed
in order to produce a symmetrical appearance. This coverage
is subject to the same deductibles and co-insurance that apply
to mastectomies under current terms. Please refer to your particular
benefit plan booklet regarding deductible and co-insurance requirements
for mastectomies.
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