Health Benefit Fund
Anthem is in the process of re-negotiating a Preferred Provider Organization (PPO) contract with "Yale Medicine" (formerly Yale Medical Group) and we have been advised by Anthem that the contract may not be settled by October 7, 2016 - the expiration date of the contract. This is a very large provider group and could affect many of the Plan Participants.
Should the contract not be settled by October 7, 2016, all services provided by Yale Medicine would be treated as "out of network" under the Health Benefits Fund rules such that, beginning October 7, 2016, services provided are subject to our Plan's deductibles, reimbursement cap (normally 80%) and "maximum allowable cost" limitation, as opposed to our "In-Network" PPO rules. Both the In-Network and Out-of-Network rules are outlined in your Summary Plan Descriptions, most generally in the Schedule of Benefits (Active Plan SPD pages 7 - 17; Retiree Plan SPD pages 7 - 17).
- If you have had services from a physician in Yale Medicine within the last year, Anthem will be sending a notification directly to you in the mail with more information.
- The Benefit Fund office is also mailing all Health Benefits Fund Members further information, including a copy of the Questions and Answer Form and the Continuation of Care form, referred to below.
Questions and Answer Form
Please review the Question and Answer Form for additional information. The Health Benefits Fund staff is also available to assist with any questions or concerns you may have regarding this situation.
Continuation of Care Form
The Board of Trustees has approved an interim policy to assist members with this potential problem of Yale Medicine and Anthem not reaching an agreement by the expiration date. This policy allows a 30 day grace period (October 7, 2016 - November 7, 2016) for appointments scheduled prior to October 7, 2016. This means that the Health Benefits Fund could continue to cover services performed under the PPO Agreement between Anthem and Yale Medicine as if the contract was in place for that 30 day grace period after October 7, 2016. This process is arranged through a Continuation of Care Form (link to Form above) that the Participant must complete for review by Anthem. Anthem works to coordinate with the Health Benefits Fund to determine whether care should be continued past October 7, 2016. If Anthem approves the form the Health Benefits Fund will pay its share towards the cost of those covered services under our Plan's "In-Network" rules.
The Board of Trustees' takes this matter and your health coverage very seriously and will continue to address additional issues should they arise.
We will continue to update the website as new developments occur.
International Union of Operating Engineers Local 478 No. Health Benefits Fund Notice of the Fund's Privacy Practices
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.
Section 1: Purpose of This Notice and Effective Date
Effective date. The initial effective date of this Notice was April 14, 2003. This 2013 Restatement is effective as of September 23, 2013, and it reflects a number of recent changes in a federal law known as the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA).
This Notice is required by law. The International Union of Operating Engineers Local No. 478 Health Benefits Fund (Fund) is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about:
- The Fund's uses and disclosures of Protected Health Information or "PHI," defined in Section 2, A,
- Your rights to privacy with respect to your PHI,
- The Fund's duties with respect to your PHI,
- Your right to file a complaint with the Fund and with the Secretary of the United States Department of Health and Human Services (HHS), and
- The person or office you should contact for further information about the Fund's privacy practices.
Section 2: Your Protected Health Information
Protected Health Information Defined
The term "Protected Health Information" or "PHI" includes all individually identifiable health information relating to your past, present or future physical or mental health condition or to payment for health care. PHI includes information maintained by the Fund in oral, written, or electronic form.
When the Fund May Disclose Your PHI
- Under the law, the Fund may disclose your PHI without your consent or authorization, and without providing you an opportunity to agree or object, in the following cases:
For treatment, payment or health care operations. The Fund and its business associates will use PHI in order to carry out your treatment, the payment of your benefits, or its health care operations:
- Treatment is the provision, coordination, or management of health care and related services. It also includes consultations and referrals between one or more of your providers. For example, your doctor or hospital may contact the Fund's employee assistance program to request authorization for certain medical treatment.
- Payment includes actions to make coverage determinations and payment (including billing, claims management, reimbursement, reviews for medical necessity and appropriateness of care and utilization review and preauthorizations). For example, the Fund may tell a doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Fund. If we contract with third parties to help us with these operations, such as companies that administer health plans or reprice claims to take advantage of discounts (e.g., Anthem), we will also disclose information to them. These third parties are known as "business associates."
- Health care operations includes quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other activities relating to creating or renewing insurance contracts. Please note that if the Fund uses or discloses PHI for underwriting purposes, it is prohibited from using or disclosing PHI that is genetic information of an individual for such purposes. Health care operations also includes disease management, case management, conducting or arranging for medical review, legal services, and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. For example, the Fund may use information about your claims to refer you into a disease management program, to refer your spouse to a well-pregnancy program, to project future benefit costs or audit the accuracy of its claims processing functions. In no event will the Fund use or disclose any of your genetic information.
- Disclosure to the Fund's Trustees. The Fund will also disclose PHI to the Fund's Board of Trustees for purposes related to treatment, payment, and health care operations, and the Board of Trustees has amended the Fund's Trust Agreement to permit this use and disclosure as required by federal law. For example, the Fund may disclose information to the Board of Trustees to allow them to decide an appeal or review a reimbursement matter. For your information, the Fund attempts to keep all appeals or requests to change the terms of the Fund's plan anonymous.
- When required by applicable law. The Fund will disclose PHI when required to do so by any federal, state or local law.
- Public health purposes. The Fund will disclose PHI to an authorized public health authority if required by law or for public health and safety purposes. PHI may also be used or disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if authorized by law. In addition, PHI may be disclosed to an appropriate government agency authorized to receive reports of child abuse or neglect.
- Domestic violence or abuse situations. The Fund will disclose PHI when authorized by law to report to public authorities information about abuse, neglect or domestic violence if a reasonable belief exists that you may be a victim of abuse, neglect or domestic violence and the Fund believes the disclosure is necessary to prevent serious harm to you or other potential victims. In such case, the Fund will promptly inform you that such a disclosure has been or will be made unless that disclosure would cause a risk of serious harm.
- Health oversight activities. The Fund will disclose PHI to a health oversight agency for oversight activities authorized by law. These activities include civil, administrative or criminal investigations, inspections, licensure or disciplinary actions (for example, to investigate complaints against health care providers) and other activities necessary for appropriate oversight of government benefit programs (for example, to the Departments of Labor or Health and Human Services).
- Legal proceedings. The Fund will disclose PHI when required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request that is accompanied by a court order, or if the Fund receives a National Medical Support Notice in connection with covering a child of yours.
- Law enforcement health purposes. The Fund will disclose PHI when required for law enforcement purposes (for example, to report certain types of wounds).
- Law enforcement emergency purposes. The Fund will disclose PHI for certain law enforcement purposes, including:
- identifying or locating a suspect, fugitive, material witness or missing person, and
- disclosing information about an individual who is or is suspected to be a victim of a crime.
- Determining cause of death and organ donation. The Fund may give PHI to a coroner or medical examiner to identify a deceased person, determine a cause of death or other authorized duties. We may also disclose PHI for cadaveric organ, eye or tissue donation purposes.
- Funeral purposes. The Fund may give PHI to funeral directors as necessary to carry out their duties with respect to the decedent.
- Research. The Fund will disclose PHI for research, provided certain strict conditions are met.
- Health or safety threats. The Fund will disclose PHI when, consistent with applicable law and standards of ethical conduct, the Fund in good faith believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat.
- Workers' compensation programs. The Fund will disclose PHI when authorized by and to the extent necessary to comply with workers' compensation or other similar programs established by law.
- Under the law, the Fund may disclose your PHI without your consent or authorization, and without providing you an opportunity to agree or object, in the following cases: For treatment, payment or health care operations. The Fund and its business associates will use PHI in order to carry out your treatment, the payment of your benefits, or its health care operations:
- When the Disclosure of Your PHI Requires Your Written Authorization:
Except as otherwise indicated in this Notice, uses and disclosures will be made only with your written authorization subject to your right to revoke your authorization. You may make a written revocation of your authorization on a prospective basis at any time. Here are a few examples:
- Disclosure to Other Benefit Funds. On certain occasions, the International Union of Operating Engineers Local No. 478 Pension Fund (Pension Fund) may need to receive information from this Fund, for example if you are determined to be disabled by the Social Security Administration. In those cases, we will request an authorization from you to release such information in order to enable the Pension Fund to process your application for retirement benefits.
- Psychotherapy notes are separately filed notes about your conversations with your mental health professional during a counseling session. They do not include summary information about your mental health treatment or medications prescribed to you. Although the Fund does not routinely obtain psychotherapy notes, it must generally obtain your written authorization before the Fund will use or disclose psychotherapy notes about you other than for treatment, payment or health care operations. However, the Fund may use and disclose such notes when needed by the Fund to defend itself against litigation filed by you.
- Marketing purposes. The Fund will request authorization for any use or disclosure of PHI for marketing, except in situations involving a face to face communication or a promotional gift of nominal value. The Fund is not in the business of marketing PHI, and it does not expect to do so in the future.
- Sale of PHI. The Fund will request authorization for any disclosure of PHI which constitutes a sale of PHI. The Fund is not in the business of selling PHI, and it does not expect to do so in the future
- Use or Disclosure of Your PHI That Requires You Be Given an Opportunity to Agree or Disagree Before the Use or Release
- Disclosure of your PHI to family members, other relatives and your close personal friends is allowed under federal law if:
- The information is directly relevant to the family or friend's involvement with your care or payment for that care, and
- You have either agreed to the disclosure or have been given an opportunity to object and have not objected.
- You should note that under certain circumstances described earlier, federal law allows the use and disclosure of your PHI without your consent, authorization or opportunity to object to such use or disclosure.
- There are also restrictions on PHI involving fundraising activities, but the Fund has never engaged in such activities. In the unlikely event the Fund engages in fundraising in the future, any fundraising communications you receive will contain a description of how to opt out of receiving such communications.
- Disclosure of your PHI to family members, other relatives and your close personal friends is allowed under federal law if:
Section 3: Your Individual Privacy Rights
The following is a description of your individual privacy rights. It is important to note that while all requests should be directed to the Fund, the Fund contracts with numerous vendors, also called "business associates," who provide services to the Fund and services and benefits to you on the Fund's behalf. Once the Fund is notified that you choose to invoke any of the individual rights listed below, it will respond or notify the appropriate vendor, as applicable, on your behalf. Because some of your PHI is maintained and used by these business associates to provide or process your benefits, the Fund requires that they administer certain aspects of the individual privacy rights.
To exercise any of the following rights, you must contact the Privacy Official, whose contact information is located in Section 6, to receive the appropriate form which you must complete in full and submit to the Privacy Official.
You May Request Restrictions on PHI Uses and Disclosures
You may request the Fund to:
- Restrict the uses and disclosures of your PHI to carry out treatment, payment or health care operations, or
- Restrict uses and disclosures to family members, relatives, friends or other persons identified by you who are involved in your care.
You May Request Confidential Communications
The Fund will accommodate an individual's reasonable request to receive communications of PHI by alternative means or at alternative locations where the request includes a statement that disclosure could endanger the individual. You will have to indicate the requested alternative means and/or locations on the form you request from and submit to the Privacy Official.
You May Inspect and Copy PHI
You have a right to inspect and obtain a copy of your PHI contained in a "designated record set" (defined below), in hardcopy or electronic form, as long as the Fund maintains the PHI. However, you do not have a right to inspect or copy psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; or PHI that is subject to law(s) that otherwise prohibits access to PHI. The Fund must provide the requested information within 30 days if the information is maintained on site or within 60 days if the information is maintained off-site. A single 30-day extension is allowed if the Fund is unable to comply with the deadline. You or your personal representative will be required to complete a form to request access to the PHI in your designated record set. A reasonable fee may be charged. Requests for access to PHI should be made to the Privacy Official, whose contact information is in Section 6.
Under limited circumstances, access may be denied. If access is denied, you or your personal representative will be provided with a written denial setting forth the basis for the denial, a description of how you may exercise your review rights and a description of how you may complain to the Fund and HHS.
The term "designated record set" includes your medical records and billing records that are maintained by or for a covered health care provider. Records include enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for a health plan or other information used in whole or in part by or for the covered entity to make decisions about you. Information used for quality control or peer review analyses and not used to make decisions about you is not included.
You Have the Right to Amend Your PHI
You have the right to request that the Fund amend your PHI or a record about you in a designated record set for as long as the PHI is maintained by the Fund in the designated record set subject to certain exceptions.
The Fund has 60 days after receiving your request to act on it. The Fund is allowed a single 30-day extension if the Fund is unable to comply with the 60-day deadline. If the Fund denies your request in whole or part, the Fund must provide you with a written denial that explains the basis for the decision. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI. You should make your request to amend PHI to the Privacy Official. See Section 6, below, for more information.
You Have the Right to Receive an Accounting of the Fund's PHI Disclosures
At your request, the Fund will also provide you with an accounting of certain disclosures by the Fund of your PHI. We do not have to provide you with an accounting of disclosures related to treatment, payment, or health care operations, or disclosures made to you or authorized by you in writing.
The Fund has 60 days to provide the accounting. The Fund is allowed a single 30-day extension if the Fund gives you a written statement of the reasons for the delay and the date by which the accounting will be provided. Also, if you request more than one accounting within a 12-month period, the Fund may charge a reasonable, cost-based fee for each subsequent accounting. You should make your request for an accounting of the Fund's disclosures of your PHI to the Privacy Official. See Section 6, below, for more information.
Your Right to a Paper Copy of this Notice
You have a right to request and receive a paper copy of this Notice at any time, even if you have received the Notice previously or agreed to receive the Notice electronically. Your request to receive a paper copy of the Notice must be made in writing to the Privacy Official, whose contact information is in Section 6.
Your Personal Representative
You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of authority to act on your behalf before the personal representative will be given access to your PHI or be allowed to take any action for you. Proof of such authority will be a completed, signed and approved Appointment of Personal Representative form which you may obtain from the Privacy Official.
The Fund retains the right to deny access to your PHI to a personal representative in the following situation. If the Fund has a reasonable belief that: (1) you have been or may be subjected to domestic abuse, violence or neglect by such person or treating such person as your personal representative could endanger you, and (2) the Fund, in its exercise of professional judgment, decides that it is not in your best interest to treat the individual as your representative.
The Fund will recognize certain individuals as personal representatives without you having to complete an Appointment of Personal Representative form. For example, absent notice of any restrictions to the contrary, the Fund will automatically consider a spouse to be the personal representative of an individual covered by the Fund. In addition, the Fund will consider a parent, guardian or other person acting in loco parentis as the personal representative of an unemancipated minor unless applicable law requires otherwise. A spouse or a minor's parent may act on an individual's behalf, including requesting access to his or her PHI. Spouses and unemancipated minors may, however, request that the Fund restrict access of PHI to family members as described in Section 3, A of this Notice.
If you have any questions about the circumstance under which the Fund will automatically consider an individual to be your personal representative, contact the Privacy Official and ask for a copy of the Fund's Policy and Procedure for the Recognition of Personal Representatives.
Section 4: The Fund's Duties
Maintaining Your Privacy; Providing You a Notice of its Privacy Practices
The Fund is required by law to maintain the privacy of your PHI and to provide you and your eligible dependents with notice of its legal duties and privacy practices with respect to PHI. The Fund is now required to notify you of anything that the law defines as a breach of your unsecured PHI, and you have a right to, and will receive, appropriate notifications in the event of any such breach.
This Notice was initially effective on April 14, 2003, and this restatement is effective as of September 23, 2013. The Fund is required to comply with the terms of this Notice. However, the Fund reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Fund prior to the effective date of this Notice. If a privacy practice is changed, a revised version of this Notice will be provided to you and to all other individuals required by law. Any revised Notice of Privacy Practices will be sent by U.S. Mail, and it will be distributed within 60 days of the effective date of any material change to: (1) the uses or disclosures of PHI, (2) your individual rights, (3) the duties of the Fund, or (4) other privacy practices stated in this Notice
Disclosing Only the Minimum Necessary Protected Health Information
When using or disclosing PHI or when requesting PHI from another covered entity, the Fund will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. However, the minimum necessary standard will not apply in the following situations:
Disclosures to or requests by a health care provider for treatment,
- Uses or disclosures made to you
- Uses or disclosures made pursuant to your authorization
- Disclosures made to the Secretary of HHS pursuant to its enforcement activities under HIPAA
- Uses or disclosures required by law, and
- Uses or disclosures required for the Fund's compliance with the HIPAA privacy regulations.
- Does not identify you, and
- Cannot reasonably be expected to identify you.
In addition, the Fund may use or disclose "summary health information" to the Fund's Board of Trustees for purposes of obtaining cost bids or modifying, amending or terminating the Fund's group health plan. Summary information summarizes the claims history, claims expenses or type of claims experienced by individuals for whom the Fund's Board of Trustees has provided health benefits under the Fund's group health plan. Identifying information will be deleted from summary health information, in accordance with HIPAA.
Section 5: Your Right to File a Complaint with the Fund or the Office of Civil Rights
If you believe that your privacy rights have been violated, you may file a written complaint with the Fund in care of the Privacy Official at the address listed in Section 6, immediately below. You may also file a complaint with the Office of Civil Rights for Connecticut's Region, which as of the date this Notice was prepared was
Peter Chan, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
JFK Federal Building - Room 1875
Boston, MA 02203
PHONE: (800) 368-1019 or (800) 537-7697 (TDD)
FAX: (617) 565-3809
The Fund will not retaliate against you for filing a complaint.
Section 6: If You Need More Information
If you have any questions regarding this Notice or the subjects addressed in it, you may contact the following official at the Fund Office:
I.U.O.E. Local No. 478 Health Benefits Fund
1965 Dixwell Avenue
Hamden, CT 06514-2400
PHONE: (203) 288-9261 / TOLL FREE: (866) 288-9261
FAX: (203) 281-3894
Section 7: Conclusion
As outlined in Section I, PHI use and disclosure by the Fund is regulated by HIPAA, as amended by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. You may find these rules at Parts 160 and 164 of Title 45 of the Code of Federal Regulations. This Notice attempts to summarize those regulations and notify you of your rights. The regulations will prevail if there is any discrepancy between the information in this Notice and the regulations.
If you are an Active Member or Retired Member of Local 478 and meet the Plan™ eligibility rules, you have excellent in-network medical benefits through an arrangement with Anthem Blue Cross and Blue Shield. You have comprehensive dental, behavioral health, prescription drug and vision coverage through various specialty networks. Because our Plan utilizes the Anthem BCBS Network, you have access to their website, which has a variety of tools to help you manage your health. All you have to do is go to their website www.anthem.com register in the top right hand corner and select a username and password.
We manage our costs to provide a high level of benefits primarily through discount agreements with network providers. With the exception of behavioral health and prescription drugs, you can usually make an appointment with an in-network practitioner without prior approval. The current co-pay for most in-network physician visits is $25, regardless of the amount the physician charges. Out-of-network medical benefits are available on an 80/20 basis after you satisfy an annual $200 deductible.
Active member benefits
Important: This is intended to be a brief description of benefits offered under the IUOE Local 478 Health Benefit Funds. The actual terms of the plan description will govern any specific situation.