IMPORTANT INFORMATION REGARDING YOUR PIEDMONT UNIFIED SCHOOL DISTRICT
MEDICAL/PRESCRIPTION DRUG BENEFITS
2011 ANNUAL COMPLIANCE NOTIFICATION
WOMEN’S HEALTH AND CANCER RIGHTS ACT REQUIRED ANNUAL NOTICE
As a Plan participant or beneficiary of Piedmont Unified School District Health Plan who elects breast reconstruction in connection to a mastectomy you will also be covered for:
- Reconstruction of the breast on which the mastectomy was performed;
- Surgery and reconstruction of the other breast to produce symmetrical appearance; and
- Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
This coverage will be provided after consultation with the attending physician and the patient, and will be subject to the same annual deductibles and coinsurance provisions that apply for the mastectomy.
This notice is provided to you for informational purposes, and no action is required on your part.
Please keep this information with your other group health plan documents. If you have any questions regarding this notice, please contact Member Services at the number found on your ID Card.
HIPAA NOTICE OF PRIVACY PRACTICES FOR PERSONAL HEALTH INFORMATION
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This notice is provided to you in accordance with federal and state privacy laws enacted to protect your medical information. This notice describes our privacy practices, our legal duties, and your rights concerning your medical information.
We are required to follow the privacy practices that are described in this notice while it is in effect. However, we reserve the right to change or privacy practices and the terms of this notice at any time, provided that applicable law permits such changes. If we make any substantive changes to our privacy practices, we will modify this notice and send you a new notice within 60 days of the change of our practices.
You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice; please contact:Piedmont Unified School District Privacy Officer and/or Benefits Manager.
This notice applies to the privacy practices of the group health plans and health insurers or health care providers listed below:
CARRIER/TPA NAME / TYPE OF COVERAGEPiedmont Unified School District / Flexible Spending Account/Section 125
Health Net / Medical
Kaiser / Medical
Delta Dental / Dental
VSP / Vision
American Fidelity / Flexible Spending Account/Section 125
USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION
We are permitted to use or disclose your protected health information (PHI) for the following purposes:
TreatmentWe may use and disclose your protected health information in order to assist your health care providers (doctors, hospitals, pharmacies, and others) in your diagnosis and treatment.
Payment We use and disclose your protected health information to pay claims from doctors, hospitals and other providers for services delivered to you that are covered by your plan, to determine your eligibility for benefits, to coordinate benefits, to examine medical necessity, to obtain premiums, or to be reimbursed by another entity that may be responsible for payment.
Health Care Operations We use and disclose your protected health information in order to perform our plan activities, such as quality assessment activities or administrative activities, including data management or customer service. In some cases, we may use or disclose your information for underwriting purposes, determining premiums, and the detection and investigation of fraud.
OTHER PERMITTED OR REQUIRED DISCLOSURES
We may also use or disclose your protected health information in support of:
As Required By Law We must disclose protected health information about you when required to do so by law.
Plan AdministrationTo the plan sponsor, to permit the plan sponsor to perform plan administration functions, as described in your plan documents.
Public Health Activities We may disclose protected health information to public health agencies for reasons such as prevention or controlling disease, injury or disability.
Business AssociatesTo persons who provide services to us and assure us they will comply with privacy regulations and our procedures on the use of protected health information.
Law Enforcement We may disclose protected health information under limited circumstances to a law enforcement official in response to a warrant or similar process; to identify or locate a suspect; or to provide information about the victim of a crime.
Research Under certain circumstances, we may disclose protected health information about you for research purposes, provided certain measures have been taken to protect your privacy.
Special Government FunctionsWe may disclose information as required by military authorities or to authorized federal officials for national security and intelligence activities.
Judicial and Administrative Proceedings We may disclose protected health information in response to a court or administrative order. We may also disclose protected health information about you in certain cases in response to a subpoena, discovery request or other lawful process.
Industry RegulationWe may disclose you protected health information to state insurance departments, the U.S. Department of Labor and other government agencies, for activities authorized by law.
Workers’ Compensation We may disclose protected health information to the extent necessary to comply with state laws for workers’ compensation programs.
Coroners, Funeral Directors, Organ DonationWe may disclose the protected health information of a deceased person to a coroner, medical examiner, funeral director, or organ procurement organization for certain purposes.
OTHER USES OR DISCLOSURES WITH AN AUTHORIZATION
Other uses or disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke an authorization at any time in writing, except to the extent that we have already taken action on the information disclosed or if we are permitted by law to use the information to contest a claim or coverage under the Plan.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Right To Access Your Protected Health Information You have the right to review or obtain copies of your protected health information records, with some limited exceptions. Usually the records include enrollment, billing, claims payment and case or medical management records. Your request to review and/or obtain a copy of your protected health information records must be made in writing. We may charge a fee for the costs of producing, copying and mailing your requested information, but we will inform you of the cost in advance.
Right To Amend Your Protected Health Information If you feel that protected health information maintained by the Plan is incorrect or incomplete, you may request that we amend the information. Your request must be made in writing and must include the reason you are seeking a change. We may deny your request if, for example, you ask us to amend information that was not created by the Plan, as is often the case for health information in our records, or you ask to amend a record that is already accurate and complete.
If we deny your request to amend, we will notify you in writing. You then have the right to submit to us a written statement of disagreement with our decision and we have the right to rebut that statement.
Right to an Accounting of Disclosures by the Plan You have the right to request an accounting of disclosures we have made of your protected health information. The list will not include our disclosures related to your treatment, our payment or health care operations, or disclosures made to you or with your authorization. The list may also exclude certain other disclosures, such as for national security purposes.
Your request for an accounting of disclosures must be made in writing and must state a time period for which you want an accounting. This time period may not be longer than six years and may not include dates before April 14, 2004. Your request should indicate in what form you want the list (for example, on paper or electronically). We may charge for providing the accounting disclosures, but we will inform you of the cost in advance.
Right To Request Restrictions on the Use and Disclosure of Your Protected Health Information You have the right to request that we restrict or limit how we use or disclose your protected health information for treatment, payment or health care operations. We may not agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency. Your request for a restriction must be made in writing. In your request, you must tell us (1)what information you want to limit; (2)whether you want to limit how we use or disclose your information, or both; and (3)to whom you want the restrictions to apply.
Right To Receive Confidential Communications You have the right to request that we use a certain method to communicate with you about the Plan or that we send Plan information to a certain location if the communication could endanger you. Your request to receive confidential communications must be made in writing. Your request must clearly state that all or part of the communication from us could endanger you. We will 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 a right at any time to request a paper copy of this Notice, even if you had previously agreed to receive an electronic copy.
Contact Information for Exercising Your Rights You may exercise any of the rights described above by contacting our privacy office. See the end of this Notice for the contact information.
If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form. Please contact Piedmont Unified School District Privacy Officer and/or Benefits Manager to obtain a copy of this notice in written form.
HEALTH INFORMATION SECURITY
We require our employees and business associates to follow Company’s security policies and procedures that limit access to health information about members to those employees and or entities that need it to perform their job responsibilities. In addition, the Company maintains physical, administrative and technical security measures to safeguard your protected health information.
COMPLAINTS
If you believe that your privacy rights have been violated, you may file a complaint with the carrier, Third Party Administrator, our Plan as listed on page one of this notice and/or with the Secretary of the Department of Health and Human Services. All complaints to the Plan, must be made in writing and sent to the address listed below.
CARRIER/TPA / REQUEST FOR ACCOUNTING / RECORD OF DISCLOSURES / FILING A COMPLAINT / QUESTIONSPiedmont Unified School District Privacy Officer / Privacy Officer
Piedmont Unified School District
760 Magnolia Avenue
Piedmont, CA 94611
Phone: (510) 594-2600
Fax: (510) 654-7374
Health Net / Health Net Privacy Office
Attn: Director, Information Privacy
P.O. Box 9103
Van Nuys, CA 91409
Phone: (800) 676-6976
Fax: (818) 676-8981
Kaiser / Write to Disclosure Accounting Coordinator, Regional Compliance and Privacy Office, 1800 Harrison Street, Oakland, CA 94612 / Member Service Call Center at 800-464-4000 (TTY 800-777-1370)
Delta / Delta Dental Subscriber Services
P.O. Box 997330
Sacramento, CA 95899-7330
(877) 335-8273
VSP / File complaints with VSP at vsp.com, or by calling our Member Services Department at 800-877-7195
American Fidelity / American Fidelity Assurance Company
P.O. Box 25523
Oklahoma City, OK 73125
866-55-HIPAA
We support your right to protect the privacy of your medical information. We will not retaliate in any way if you choose to file a complaint with us, the carriers, the Third Party Administrators listed above, or the Department of Health and Human Services.
1
Important Notice from Piedmont Unified School District About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Piedmont Unified School District and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1.Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2.Piedmont USD has determined that the prescription drug coverage offered by the Piedmont USD is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Piedmont USD coverage may be affected
As part of Piedmont USD’s prescription drug benefit program, your prescription coverage includes coverage for generic and brand name prescriptions. There is also the option for mail order prescriptions. Please see your benefit summary for more information. In addition, your current coverage pays for other health expenses, in addition to prescription drugs, and you will still be eligible to receive all of your current health and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan.
If you do decide to join a Medicare drug plan and drop your current Piedmont USD coverage, be aware that you and your dependents will be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Piedmont USD and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Piedmont USD changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
- Visit
- Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help
- Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at 1-800-772-1213 (TTY 1-800-325-0778).