VII.
COBRA, HIPAA, Newborns’ Act, and WHCRA
Continuing Your Health
Coverage under COBRA
If you lose eligibility for TeamstersCare
medical benefits for reasons called “qualifying events,”
you can continue your health coverage under a Federal law
called COBRA (Consolidated Omnibus Budget Reconciliation
Act of 1985).
Under COBRA, you can maintain your
current TeamstersCare health coverage (i.e., under a TeamstersCare
HMO or the TeamstersCare Tufts Out of Area Option)—or
you can switch from one Option to another if you meet the
requirements (example: moving into an HMO service area).
You will have to pay the full cost of your health benefits,
plus a 2% administration fee, through monthly premiums.
COBRA affects only your healthcare
benefits. The law does not provide for continuation of
other coverages, such as life, disability, or AD&D
insurance. However, while you are covered by COBRA, the
Plan will continue to provide you with certain TeamstersCare
clinical services benefits, at no additional cost to you. (See SECTION V, CLINICAL SERVICES BENEFIT.) You may also elect to continue
dental and vision care benefits by paying a higher monthly
premium.
When you become eligible for COBRA,
you can extend coverage for yourself, your spouse, and
your dependents who were covered at the time of the qualifying
event. In addition, during the period when you are covered
by COBRA, the following persons are also automatically
eligible:
• any newborn
or adopted child added to your family
• any child placed
with you (the member) for adoption
• a spouse who
becomes your dependent if you marry
To enroll these new dependents,
you must notify Charlestown Member Services within 31
days of the birth, adoption, or marriage. Your newborn
or adopted child(ren) or child(ren) placed for adoption
with you during your period of COBRA continuation coverage
are considered qualified beneficiaries and have independent
rights to elect and change elections under COBRA. However,
your new spouse or other dependents added during your
COBRA continuation coverage period are not qualified
beneficiaries and do not have independent COBRA rights.
FImportant
Note: COBRA continuation of coverage is authorized by Federal
law. If the law changes, then eligibility for continued coverage
might also change.
Types of Coverage
When you elect COBRA, you can choose
one of two levels of coverage:
either
• Option #1:
medical
benefits, prescription drug coverage, hearing care, mental
health
& substance abuse benefits, and health screenings at the
TeamstersCare Wellness Offices
or
• Option #2:
medical benefits,
prescription drug coverage, hearing care, mental health & substance
abuse benefits, health screenings at the TeamstersCare Wellness
Offices, plus dental and vision care benefits
Once you elect one of these two
options, you cannot change your decision during your
period of COBRA coverage. (Remember, however, that during
any Annual Enrollment period, you can choose to switch
between the available Options for your basic medical
benefits provided you meet the medical Option’s
service area requirements.)
The Period for Making
Your Decision About COBRA Coverage
To continue coverage under COBRA,
you have to submit a TeamstersCare Benefit
Continuation Form. You or your eligible dependents must complete and return
this Form to
TeamstersCare sometime within 60 days of the later of two
dates:
• either the date you receive notice of your rights to continue
coverage under the Plan
• or the date your TeamstersCare coverage ends
Cost of Continued
Coverage
You and your covered dependents will
be required to pay 102% of the full group cost for your
continued coverage. (However, this cost may be increased
to 150% for a qualified 11-month extension of coverage
due to disability. See Continuing
Coverage While Disabled, click here,
or, for more details, call Charlestown Member Services.)
FImportant
Note: COBRA rates change from time to time, depending on
the general cost of healthcare, cost variations among different
providers, and the Federal government’s decisions about
COBRA benefits and administration. If COBRA costs or benefits
change in the future, we will let you know ahead of time.
For current coverage costs, contact Charlestown Member Services.
Your first COBRA payment
is due no later than 45 days after the date you (or a dependent)
elect continued coverage. After you’ve paid this first
premium, you need to continue making payments by the first
of every month. However, each month, you have a 30-day grace
period in which to pay your premium.
FImportant
Note:
During
a premium-payment “grace period”:
• your eligibility
cannot be confirmed nor your claims processed until the premium
has been paid, and
• you cannot have
a prescription filled at a TeamstersCare or RESTAT pharmacy
The first COBRA payment is retroactive
to the date of your “qualifying event,”
loss of coverage, or the date you became ineligible because
of insufficient hours.
(See SECTION II, PARTICIPATION.)
Qualifying Events
Continuing Coverage for up to 18 Months
You and your spouse and/or
dependents can continue health benefits for up to 18 months
if the Fund receives timely notice that you are losing
coverage for any one of these “qualifying events”:
• you don’t
work enough hours in an eligibility determination period
or
• you retire and
subsequently lose coverage
or
• your job ends
for any other reason (other than your gross misconduct)
Continuing Coverage While Disabled
Under certain circumstances,
you and your dependents may be able to extend medical benefits
for a total of 29 months—11 additional months beyond
the original 18 months of COBRA continuation coverage.
This occurs when you or a covered dependent:
• is disabled
under Title II or XVI of the Social Security Act when you
stop working for any of the “qualifying events” named
above
• becomes disabled
under Title II or XVI of the Social Security Act anytime
during the first 60 days of your initial 18-month COBRA coverage
period
Sometime during your first 18 months
of continued coverage, you need to obtain a special determination
letter from the Social Security Administration (SSA)
saying that you or your dependent was disabled under
Title II or XVI of the Social Security Act when your
qualifying event occurred, or during the first 60 days
of your initial
18-month COBRA coverage period.
You must then notify TeamstersCare
in writing and provide a copy of the SSA disability determination
letter sometime during this same 18-month continuation
period and no later than 60
days after you’ve received your disability determination
from Social Security.
Termination of coverage during the
29-month period will occur if you or your dependent is
found by the Social Security Administration to be no longer
disabled. Termination will occur on the first day of the
month beginning more than 30 days after the date of the
final determination. All reasons for termination that apply
to the initial 18 months will also apply for any additional
months of coverage.
Continuing Dependent Coverage for up
to 36 Months
In some cases, your dependents
can have coverage extended for a total of up to 36 months.
Dependents may be eligible for 36 months of continued medical
benefits if they would otherwise
be losing coverage for any one of the following “qualifying
events”:
• your death
• your divorce
or legal separation
• your entitlement
to Medicare
• your dependent
no longer meets the Plan’s definition of “eligible
dependent”
This 36-month continuation
period begins at different times, depending on the particular “qualifying
event,” as follows:
• Your
death. Remember that your dependents will continue to receive
TeamstersCare health benefits after your death for up to
three months beyond the benefits coverage period when they
were last eligible. (See “What happens to coverage when a member or dependent
dies?,” click
here.) At the end of that three-month period, your dependents
can then elect to continue their extended coverage, under
COBRA, for an additional 36 months.
• Your
divorce or legal separation. The
36-month continuation period begins with the date of divorce
or separation.
• Your
entitlement to Medicare. The
36-month continuation period begins when you become entitled
to Medicare and your dependents would otherwise lose coverage.
• Your
dependent no longer meets the Plan’s definition of “eligible
dependent.” The
36-month continuation period starts on the date when the
dependent no longer qualifies as a dependent under the Plan.
COBRA and Medicare
You are eligible to continue
healthcare benefits under COBRA if you become entitled
to Medicare and then have a COBRA qualifying event. However,
you are not eligible to continue your healthcare benefits
if you have a qualifying event and then first become entitled
to Medicare after you elect COBRA continuation coverage.
Your dependents can still continue their own medical benefits,
provided they have not become covered under some other
group health plan. For dependents, this continuation extends
for one of two periods, depending on which of the two provides
coverage longer:
• either 36 months from the date you first became covered by
Medicare
• or for 18 months following the date of the qualifying
event
Example
Suppose you’re an active Plan
member and you turn 65 (and so become covered by Medicare)
on March 1, 2004. One year later, as of February 28,
2005, you retire and then subsequently lose Plan eligibility—which
is a
“qualifying event.” You are generally eligible
for 18 months of COBRA continuation coverage.
Your dependents would be eligible
to continue benefit coverage until:
• either 36 months following the date you first became covered
by Medicare—
which would extend coverage until March 1, 2007
• or 18 months following the date of the qualifying event—which
would extend coverage through August 31, 2006
In this example, since the 36-month
continuation gives your dependent the longer of the two
coverages, it’s this 36-month period that applies.
More Than One Qualifying Event for
Your Dependents
If your dependents become
eligible to continue their coverage under more than one “qualifying
event,” they may be able to extend their health benefits
for up to a combined total of 36 months. This total 36-month
period begins on the date of the first “qualifying
event.”
Example
Suppose you lose eligibility
under one of the “qualifying events” that provides
your dependent child with 18 months’ continuation
coverage—your retirement would be an example.
Sometime during that initial 18-month
continuation coverage period, your dependent child no longer
meets the plan’s definition of “dependent.”
(For example, you reach December 31 of the year in which
your dependent has turned age 19 and is no longer a full-time
student.) This is a second “qualifying event.”
Your child may then be eligible for
additional extended coverage up to a total of 36 months.
This 36-month period would begin on the date of the first
qualifying event—your retirement.
Notification of a Qualifying Event
TeamstersCare’s
responsibility. If you qualify for COBRA and the Fund receives timely
notice from your employer that you are losing coverage
because you failed to work the required number of hours,
then TeamstersCare will take the first action—by
notifying you and/or your covered dependents of COBRA eligibility.
FImportant
Note: To protect your family’s rights under COBRA, it is
important for you to keep the
Plan Administrator informed of any changes in the addresses of your family members. You should also keep a copy, for
your records, of any notices you send the Plan Administrator.
Your responsibility. However,
for certain other “qualifying events,” you or
a family member must take the first step in the process by
notifying TeamstersCare of the event. You, your spouse, or
a dependent is responsible for this notification if eligibility
would otherwise end because:
• you become divorced
or legally separated
• your dependent
child no longer meets the Plan’s definition of “eligible
dependent”
For these events, you or your
family member must notify TeamstersCare in writing within
60 days of the later of two dates:
• either the date of the “qualifying event”
• or the date TeamstersCare coverage ends
If you do not notify TeamstersCare
within 60 days of the event, coverage will terminate.
When COBRA Continued
Coverage Ends
If your coverage has been continued
for any of the reasons described above, including disability,
the extended coverage will end when any one of the following
happens:
• You or your
dependent fails to pay the cost of continued coverage before
the end of a grace period extension. (See Cost of Continued Coverage, click
here.)
• You become covered
under some other employer’s group health plan (either
as an employee or dependent) after you have already elected
COBRA continuation coverage. (This does not apply if the
other plan limits or pays no benefits for a medical condition
you or a dependent already has.)
• You first become
entitled to Medicare—relative to your own coverage—after
you elect COBRA coverage.
• Your spouse
or dependent becomes entitled to Medicare—relative
to his or her own coverage—after he/she elects COBRA
coverage.
• Coverage was
continued due to a disability and then Social Security determines
you or your dependent is no longer disabled. (In this case,
termination will occur
on the first day of the month beginning more than 30 days after
the date of the
final determination.)
• Continued coverage
reaches the 18-, 29-, or 36-month limit—whichever applies.
If You Don’t
Elect COBRA Coverage
When you’re deciding whether
or not to continue your health benefits under COBRA, you
should be aware of certain consequences that follow if
you choose not to elect COBRA.
First.
If, after losing TeamstersCare benefits, you remain uncovered for more than 63 days before joining another group health plan, then
you lose your right to be exempt from any restrictions
which that other plan might impose on pre-existing conditions.
Second.
If, after losing TeamstersCare benefits, you
do not elect COBRA coverage for the maximum time you’re
permitted under the law, then
you lose your right—when purchasing an
individual policy—to be exempt from any restrictions that other policy
might impose based on pre-existing conditions.
Third.
You have special enrollment rights that allow you to join
another group health plan (for example, your spouse’s
plan) within 30 days after losing TeamstersCare eligibility.
You will also have this right at the end of your COBRA
coverage, provided you elect COBRA for the maximum time
it’s available to you.
If You Have Questions
about COBRA
If you have questions about your COBRA
continuation coverage, you should contact the Plan Administrator
or you may contact the nearest Regional or District Office
of the U.S. Department of Labor’s Employee Benefits
Security Administration (EBSA). Additional information
is also available through EBSA’s website at www.dol.gov/ebsa.
EBSA Headquarters:
Division of Technical Assistance
and Inquiries
Employee Benefits Security
Administration
U.S. Department of Labor
Frances Perkins Building
200 Constitution Avenue N.W.
Washington, D.C. 20210
1-202-219-8776
toll free: 1-866-444-EBSA (3272)
EBSA Boston Regional Office:
Employee Benefits Security
Administration
Boston Regional Office
J.F.K. Building, Room 575
Boston, MA 02203
1-617-565-9600
Your Rights under
HIPAA
The Health
Insurance Portability and Accountability Act of 1996 (HIPAA)
is a Federal
law that helps protect the continuity of health benefits
coverage. HIPAA:
• limits exclusions
for pre-existing medical conditions
• credits prior
health coverage in the form of certificates
• prohibits discrimination
in enrollment or in premiums charged, based on
health-related factors
• guarantees renewability
of health insurance coverage in the group insurance markets
• preserves the
states’
role in regulating health insurance
HIPAA helps individuals who lose
coverage under one health plan to get coverage under
another plan, in cases where that second plan may have “pre-existing
condition”
exclusions. HIPAA requires the “second plan” to
reduce the length of its pre-existing exclusion period
by the amount of time the individual was covered under
the previous plan.
Since our TeamstersCare Plan does
not have “pre-existing condition” limitations,
participants who lose TeamstersCare eligibility and are
looking for new coverage may encounter this problem for
the first time. HIPAA entitles individuals to get a “certificate” from
their previous plan that documents the length of their
prior health coverage. This certificate can then be used
to reduce whatever pre-existing condition exclusions might
be imposed by the new plan.
This HIPAA certification requirement
applies only when you or your dependent(s) lose eligibility
for TeamstersCare health benefits.
For members who lose eligibility,
TeamstersCare will issue a certificate—reflecting
the single most recent period of continuous coverage—under the following circumstances:
• automatically
– when certification
is required under HIPAA
– when an individual
who is losing eligibility under the Plan is not entitled
to COBRA
– when an individual
has been covered by COBRA, but then COBRA coverage ends—this
is true even when the individual may have previously received
a certificate verifying earlier, pre-COBRA coverage under
TeamstersCare
• upon
request—before losing coverage or within 24 months of losing
coverage
If you need such a certificate,
call Charlestown Member Services.
Privacy & Notice
of TeamstersCare Privacy Policies
TeamstersCare is required by law to
maintain the privacy of your protected
health information (PHI)
and to provide you notice of TeamstersCare’s legal
duties and privacy practices with respect to this health
information. PHI includes information which:
• identifies you,
and
• relates to your
past, present or future physical or mental health or condition,
the provision of health care to you, or the payment for that
care
If you have questions about any
part of this Notice, or if you want more information
about our privacy practices, please contact the TeamstersCare
Privacy Official at 16 Sever Street, Charlestown, MA
02129, or you may call 617-241-9220.
How TeamstersCare May Use or Disclose
Your Protected
Health Information
The following categories describe
the ways that TeamstersCare may use and disclose your protected
health information. We have not listed every use or disclosure
that might be included in a given category. However, all
the ways we are permitted to use and disclose information
fall within one of these categories.
Treatment.
Information obtained by a TeamstersCare provider, for example
a dentist or pharmacist, may be disclosed to other healthcare
providers who are part of your healthcare team in order
to provide you with the best course of treatment.
Payment.
We may use or disclose PHI about you to determine eligibility
for plan benefits, obtain premiums, facilitate payment
for the treatment and services you receive from health
care providers, determine plan responsibility for benefits,
and to coordinate benefits. For example, the “payment” category
may include determining whether TeamstersCare covers a
particular treatment.
Health Care Operations. We may use and disclose PHI about you to carry out necessary
insurance-related activities. Such activities could include
underwriting, premium rating and other activities relating
to plan coverage; conducting or arranging for medical review,
legal services, and audit services; and business planning,
management, and general administration.
Required by Law.
We will disclose your PHI when required to do so by federal,
state or local laws. For example, we may disclose your
PHI to the U.S. Department of Health and Human Services
upon their request if they wish to determine whether
we are in compliance with federal privacy laws.
Public Health.
As required by law, we may disclose your PHI to public
health authorities for purposes related to: preventing
or controlling disease, injury, or disability; reporting
child abuse or neglect; reporting domestic violence; reporting
to the Food and Drug Administration problems with products
and reactions to medications; and reporting disease or
infection exposure.
Health Oversight Activities. We may disclose your PHI to health agencies, as authorized by
law, during the course of audits, investigations, inspections,
licensure, and other proceedings related to oversight of
the health care system.
Judicial and Administrative Proceedings. We may disclose your PHI in the course of a judicial or
administrative proceeding, such as a lawsuit, in response
to a subpoena.
Law Enforcement.
As required by law, we may disclose your PHI to a law enforcement
official for purposes such as identifying or locating a
suspect, fugitive, or missing person; complying
with a valid court order or subpoena; and for other law
enforcement purposes.
Coroners, Medical Examiners and
Funeral Directors. We may disclose your PHI to coroners, medical examiners,
and funeral directors. For example, this may be needed
in order to identify a deceased person or determine the
cause of death.
Organ and Tissue Donation. Consistent with applicable law, we may disclose your PHI to organizations
involved in procuring, banking, or transplanting organs
and tissues.
Public Safety.
We may disclose your PHI to appropriate persons in order
to prevent or lessen a serious and imminent threat to the
health or safety of a particular person or the general
public.
National Security.
We may disclose your PHI to authorized federal officials
for military intelligence and national security purposes
as authorized by law.
Correctional Institutions. We may disclose your PHI to a correctional institution, if you
are an inmate, as necessary for your health.
Workers’ Compensation. We may disclose your PHI as necessary to comply with Workers’
Compensation or similar laws.
Marketing.
We may contact you to give you information about health-related
benefits and services that might interest you.
Disclosures to Trustees. If you appeal a claim to the TeamstersCare Board of Trustees,
we may disclose limited PHI necessary for the purpose of
administering plan benefits.
When TeamstersCare May Not Use or Disclose
Your
Protected Health Information
Except as described in this
Notice of Privacy Practices, we will not use or disclose
your protected health information without written authorization
from you. If you do authorize us to use or disclose your
PHI for another purpose, you may revoke your authorization
in writing at any time. If you revoke your authorization,
we will no longer be able to use or disclose PHI about
you for the reasons covered by your written authorization,
though we will be unable to take back any disclosures we
have already made with your permission.
Statement of Your Health Information
Rights
Right to Inspect and Copy. You have the right to inspect and copy PHI about you in TeamstersCare
records that may be used to make decisions about your plan
benefits.
To inspect or copy such information, you must submit your request
in writing to the TeamstersCare Privacy Official, 16 Sever
Street, Charlestown, MA 02129. If you request a copy of
the information, we may charge you a reasonable fee to
cover expenses associated with your request. We may deny
your request to inspect or copy in certain limited circumstances.
In such cases we will provide you with an explanation for
the denial.
Right to Request Restrictions. You have the right to request restrictions on certain uses and
disclosures of your PHI. TeamstersCare may not be able
to comply with all requests.
If you would like to make a request for restrictions, you
must submit your request in writing to the TeamstersCare
Privacy Official, 16 Sever Street, Charlestown, MA 02129.
Right to Request Confidential
Communications. You have the right to receive your PHI through a reasonable
alternative means or at an alternative location. To request
confidential communications, you must submit your request
in writing to the TeamstersCare Privacy Official, 16 Sever
Street, Charlestown, MA 02129. TeamstersCare may not be
able to comply with all requests.
Right to Request Amendment. You have the right to request that TeamstersCare amend your PHI
when you believe the information is incorrect or incomplete.
We are not required to change your PHI and if your request
is denied, we will provide you with information about our
denial and how you can appeal the denial. To request an
amendment, you must make your request in writing to the
TeamstersCare Privacy Official, 16 Sever Street, Charlestown,
MA 02129. You must also provide a reason for your request.
Right to Accounting of Disclosures. You have the right to receive a list or “accounting
of disclosures” of your PHI made by us, except that
we do not have to account for disclosures made for purposes
of treatment, payment or health care operations, disclosures
made to you or others involved in your care, or disclosures
that you authorize. To request this accounting of disclosures,
you must submit your request in writing to the TeamstersCare
Privacy Official, 16 Sever Street, Charlestown, MA 02129.
Your request should specify a time period of up to six
years and may not include dates before April 14, 2003.
Upon your request, TeamstersCare will provide you with
one list per 12-month period free of charge. We may charge
you for additional lists.
Right to Paper Copy.
You have the right to receive a paper copy of this Notice
of TeamstersCare Privacy Practices at any time. To obtain
a paper copy of this Notice,
send your written request to the TeamstersCare Privacy Official,
16 Sever Street, Charlestown, MA 02129. You may also obtain
a copy of this Notice at our website, www.teamsterscare.com.
If you would like to have a more detailed
explanation of these rights or if you would like to exercise
one or more of these rights, contact the TeamstersCare
Privacy Official, at 16 Sever Street, Charlestown, MA 02129
or you may call 617-241-9220.
Changes to this Notice of Privacy Practices
TeamstersCare reserves the
right to amend this Notice of Privacy Practices at any
time
in the future and to make the new Notice provisions effective
for all protected health information that it maintains.
We will promptly revise our Notice and distribute it
to you whenever we make material changes to the Notice.
Until such time, TeamstersCare is required by law to
comply with the current version of this Notice.
For More Information or to Report a
Problem
If you have questions about
this Notice of Privacy Practices, or about how we handle
your PHI, you may contact the TeamstersCare Privacy Official,
16 Sever Street, Charlestown, MA 02129. If you believe
your privacy rights have been violated, you can file a
complaint with the TeamstersCare Privacy Official. All
complaints to TeamstersCare must be submitted in writing.
TeamstersCare will not retaliate against you in any way
for filing a complaint. You may also file a complaint with
the Secretary of the Department of Health and Human Services,
200 Independence Avenue, S.W., Washington D.C. 20201. The
secretary may be reached by phone at 202-690-7000.
Your Rights Under
the Newborns’ and Mothers’ Health Protection
Act
The Newborns’ and Mothers’
Health Protection Act of 1996 (Newborns’ Act) puts the decisions affecting length of hospital stays after
childbirth in the hands of mothers and attending providers.
The Newborns’ Act and its regulations
provide that health plans may not restrict a mother’s
or newborn’s benefits, for a hospital length of stay
related to childbirth, to less than 48 hours following
a vaginal delivery or 96 hours following a delivery by
cesarean section. (The attending provider may, in consultation
with the mother, discharge earlier.)
The Newborns’ Act prohibits
any incentives, either positive or negative, that could
encourage less than the minimum protections under the Act.
The Plan may apply its regular deductibles
and copayments, provided they do not increase during
the mandated minimum hospital stay (for example, by requiring
a higher copayment after the first 24 hours of hospitalization).
All TeamstersCare Medical Options
are required to adhere to this act by law.
Your Rights Under
the Women’s Health and
Cancer Rights Act
The Women’s Health and Cancer
Rights Act (WHCRA), signed into law on October 16, 1998,
contains protections for breast cancer patients who elect
breast reconstruction in connection with a mastectomy.
Plans offering coverage for a mastectomy must also cover
reconstructive surgery related to the mastectomy.
When a plan provides coverage with
respect to a mastectomy, coverage is required for reconstructive
surgery in a manner determined in consultation with the
attending physician and the patient.
Reconstructive benefits must include
coverage for:
• reconstruction
of the breast on which the mastectomy has been performed
• surgery and
reconstruction of the other breast to produce a symmetrical
appearance
• prosthesis and
physical complications at all stages of mastectomy,
including lymphedemas
These benefits are subject to the
plan’s regular copayments.
The law also prohibits plans from:
• denying a patient’s
eligibility or continued eligibility in order to avoid the
requirements of the WHCRA, or
• establishing
incentives, penalties, or inducements for care in a manner
inconsistent with the WHCRA
