Compliance Guide - the Hearthstone

2016-2017
Compliance
Guide
Presented By:
1
Introduction
This booklet contains mandatory annual notices regarding your health and welfare benefit plans through The
Hearthstone for the plan year July 1, 2016 to June 30, 2017. Please review these notices carefully and
contact us if you have any questions.
Human Resources Department
The Hearthstone
John Paulson
6720 East Green Lake Way N
Seattle, WA 98103
206.517.2275
[email protected]
2
Summary of Benefits and Coverage – Group Health
Access PPO
3
Summary of Benefits and Coverage – Group Health
Access PPO continued
4
Summary of Benefits and Coverage – Group Health
Access PPO continued
5
Summary of Benefits and Coverage – Group Health
Access PPO continued
6
Summary of Benefits and Coverage – Group Health
Access PPO continued
7
Summary of Benefits and Coverage – Group Health
Access PPO continued
8
Summary of Benefits and Coverage – Group Health
Access PPO continued
9
Summary of Benefits and Coverage – Group Health
Access PPO continued
10
Summary of Benefits and Coverage – Group Health
HMO $200
11
Summary of Benefits and Coverage – Group Health
HMO $200 continued
12
Summary of Benefits and Coverage – Group Health
HMO $200 continued
13
Summary of Benefits and Coverage – Group Health
HMO $200 continued
14
Summary of Benefits and Coverage – Group Health
HMO $200 continued
15
Summary of Benefits and Coverage – Group Health
HMO $200 continued
16
Summary of Benefits and Coverage – Group Health
HMO $200 continued
17
Summary of Benefits and Coverage – Group Health
HMO $200 continued
18
Important Notices
Women’s Health and Cancer Rights
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires that a group health plan, which
provides coverage for a mastectomy, must also include coverage for reconstructive surgery and prostheses
following the mastectomy. The law mandates that a participant or eligible beneficiary who is receiving
benefits for a covered mastectomy and who elects breast reconstruction in connection with the mastectomy,
will also receive coverage for:
•
•
•
•
all stages of reconstruction of the breast on which the mastectomy has been performed;
surgery and reconstruction of the other breast to produce a symmetrical appearance;
prostheses; and
treatment of physical complications of all stages of mastectomy, including lymphedemas.
Coverage will be provided in a manner determined in consultation with the patient and the patient’s attending
physician. Benefits will be provided subject to the same deductible and coinsurance applicable to other
medical and surgical benefits provided under the plan.
If you have any questions about coverage for mastectomies and post-operative reconstructive surgery, please
contact your medical plan insurance company.
As required under the law, this notice is to be provided upon enrollment and annually thereafter.
Newborns’ and Mothers’ Health Protection
Under the Newborns' and Mothers' Health Protection Act of 1996, group health plans and health insurance
issuers offering group health insurance generally may not restrict benefits for any hospital length of stay in
connection with childbirth for the mother or the newborn child to less than 48 hours following a vaginal
delivery, or less than 96 hours following a cesarean section. However, the plan or issuer may pay for a
shorter stay if the attending physician (e.g., your physician, nurse, or midwife, or a physician assistant), after
consultation with the mother, discharges the mother or newborn earlier.
Also, under federal law, plans and insurers may not set the level of benefits or out-of-pocket costs so that any
later portion of the 48-hour or (96-hour) stay is treated in a manner less favorable to the mother or newborn
than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider
obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain
providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain pre-certification.
For information on pre-certification, please contact your medical plan insurance company.
19
Important Notices
HIPAA Special Enrollment Rights
Below outlines important information for individuals who are eligible to participate in The Hearthstone medical
plan (to actually participate, you must complete an enrollment form and may be required to pay part of the
premium through payroll deduction).
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that you be notified about
two very important provisions in The Hearthstone medical plan. The first is your right to enroll in the medical
plan under the “special enrollment provision” if you acquire a new dependent, or you or an eligible dependent
decline coverage under the plan because of alternative coverage and later lose such coverage due to certain
qualifying reasons. Second, this notice advises you of the plan’s preexisting condition exclusion rules that
may temporarily exclude coverage for certain preexisting conditions that you or your family may have.
I. SPECIAL ENROLLMENT RIGHTS
Rule #1 – Loss of Coverage. If you are declining enrollment for yourself or your dependents (including your
spouse) because of other health insurance coverage for such individuals, and that coverage terminates due to
certain qualifying reasons (i.e., exhaustion of COBRA or state law continuation rights; loss of eligibility for
other coverage due to legal separation, divorce, death, termination of employment or reduction in hours; or
because employer contributions for other non-COBRA coverage ceases) you “may” in the future be able to
enroll yourself or your dependents (whose coverage terminates for a qualifying reason) in the plan, provided
that you request enrollment within 30 days after your other coverage ends, and that you meet certain other
important conditions described in the plan SPD (Summary Plan Description).
Rule #2 – Marriage, Birth or Adoption. In addition, if you acquire a new dependent as a result of marriage,
birth, adoption, or placement for adoption, you “may” be able to enroll yourself, your spouse, and your newly
acquired dependent(s), provided that you request enrollment within 30 days after the marriage, birth,
adoption, or placement for adoption, and that you meet certain other important conditions described in the
plan SPD.
Rule #3 – Marriage Equality Act: The Marriage Equality Act revised the rules regarding domestic
partnerships in Washington effective June 30, 2014. Under the revised rules, domestic partnerships (samesex or opposite- sex partners) may register only if at least one of the partners is age 62 or older and the other
eligibility conditions outlined in the State Employment Laws are met. Also, under the Marriage Equality Act,
same-sex domestic partnerships that were entered into before June 30, 2014, and have not been dissolved or
converted into marriages automatically converted into marriages as of June 30, 2014, unless one of the
partners is age 62 or older.
20
Important Notices
Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
21
Important Notices
Children’s Health Insurance Program (CHIP) continued
22
Important Notices
Children’s Health Insurance Program (CHIP) continued
23
Important Notices
Your Prescription Drug Coverage & Medicare Part D
Please read this notice carefully and keep it where you can find it. This notice has information about your
current prescription drug coverage with The Hearthstone and prescription drug coverage available for people
with Medicare. It also explains the options you have under Medicare prescription drug coverage and can help
you decide whether or not you want to enroll. At the end of this notice is information about where you can get
help to make decisions about your prescription drug coverage.
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. Coverage
may be purchased from insurance carriers that offer Medicare prescription drug plans and Medicare
Advantage Plans that include prescription drug coverage. All Medicare prescription 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. The Hearthstone has determined that the prescription drug coverage offered by the both Group Health
Cooperative and Group Health Options Benefit Plans is, on average for all plan participants, expected to
pay out as much as the standard Medicare prescription drug coverage will pay and is 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 through 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.
Your current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a
Medicare prescription drug plan, you and your eligible dependents will still be eligible to receive all of your
current health and prescriptions drug benefits.
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 The Hearthstone coverage will not be affected.
If you do decide to join a Medicare drug plan and drop your current The Hearthstone coverage, be aware that
you and your dependents will be able to get this coverage back. See pages 7-9 of the CMS Disclosure of
Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at
http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options
that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D.
If you do decide to join a Medicare drug plan and drop your current The Hearthstone coverage, be aware that
you and your dependents will be able to get this coverage back.
24
Important Notices
Your Prescription Drug Coverage & Medicare Part D continued
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 coverage with The Hearthstone 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 November to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage…
Contact the person listed below for further information or call the customer service number on the back of
your medical insurance ID card. 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 The Hearthstone changes. You also
may request a copy of this notice from us 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. If you are Medicare eligible, 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 plans:
Visit medicare.gov
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 drug coverage is available. For
information about this extra help visit Social Security on the web at socialsecurity.gov, or call them at
1.800.772.1213 (TTY 1.800.325.0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug
plans, you may be required to provide a copy of this notice when you join to show whether or not
you have maintained creditable coverage and, therefore, whether or not you are required to pay a
higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact – Position/Office:
Address:
Phone Number:
May 12, 2016
The Hearthstone
John Paulson
6720 East Green Lake Way N Seattle, WA 98103
206.517.2275
25
Important Notices
Reminder of Continuation of Coverage Under COBRA
Introduction
You are receiving this notice because you have recently become covered under a group health plan (the
Plan). This notice contains important information about your right to COBRA continuation coverage, which is
a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation
coverage, when it may become available to you and your family, and what you need to do to protect
the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you
would otherwise lose your group health coverage. It can also become available to other members of your
family who are covered under the Plan when they would otherwise lose their group health coverage. For
additional information about your rights and obligations under the Plan and under federal law, you should
review the Plan’s Summary Plan Description or contact the Plan Administrator.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end
because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice.
After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified
beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage
under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect
COBRA continuation coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan
because either one of the following qualifying events happens:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under
the Plan because any of the following qualifying events happens:
•
•
•
•
•
Your spouse dies;
Your spouse’s hours of employment are reduced;
Your spouse’s employment ends for any reason other than his or her gross misconduct;
Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any
of the following qualifying events happens:
•
•
•
•
•
•
The parent-employee dies;
The parent-employee’s hours of employment are reduced;
The parent-employee’s employment ends for any reason other than his or her gross misconduct;
The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
The parents become divorced or legally separated; or
The child stops being eligible for coverage under the plan as a “dependent child.”
26
Important Notices
Reminder of Continuation of Coverage Under COBRA continued
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator
has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or
reduction of hours of employment, death of the employee, or the employee’s is becoming entitled to Medicare
benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying
event.
You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent
child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60
days after the qualifying event occurs. You must provide this notice to:
Northwest Administrators COBRA Department
2323 Eastlake Avenue E
Seattle, WA 98102
206.926.2816
How is COBRA Coverage Provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation
coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an
independent right to elect COBRA continuation coverage. Covered employees may elect COBRA
continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on
behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the
death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both),
your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA
continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of
employment or reduction of the employee's hours of employment, and the employee became entitled to
Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for
qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement.
For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his
employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months
after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36
months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the
employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18
months. There are two ways in which this 18-month period of COBRA continuation coverage can be
extended.
27
Important Notices
Reminder of Continuation of Coverage Under COBRA continued
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to
be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be
entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29
months. The disability would have to have started at some time before the 60th day of COBRA continuation
coverage and must last at least until the end of the 18-month period of continuation coverage. Requests for
disability extension must be made in writing to the plan administrator.
Northwest Administrators COBRA Department
2323 Eastlake Avenue E
Seattle, WA 98102
206.926.2816
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation
coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA
continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given
to the Plan. This extension may be available to the spouse and any dependent children receiving continuation
coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part
B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan
as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage
under the Plan had the first qualifying event not occurred.
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the
contact or contacts identified below. For more information about your rights under ERISA, including COBRA,
the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans,
contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security
Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone
numbers of Regional and District EBSA Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the
addresses of family members. You should also keep a copy, for your records, of any notices you send to the
Plan Administrator.
Plan Administrator Contact Information
You may obtain information about the Plan and COBRA coverage on request from:
Northwest Administrators COBRA Department
2323 Eastlake Avenue E
Seattle, WA 98102
206.926.2816
28
Important Notices
Exchange Model Notice
29
Important Notices
Exchange Model Notice continued
30
This compliance guide created for The Hearthstone by Brown & Brown Insurance