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CHESTNUT HILL COLLEGE 2013
EMPLOYEE BENEFITS GUIDE
DECEMBER 1, 2013 TO NOVEMBER 30, 2014
Prepared by:
This booklet gives you an overview of the main features of your benefits plan. The plans are administered according to
legal plan documents and insurance contracts. Although we have tried to summarize the provisions of these legal
documents clearly and accurately, if any information presented here conflicts with the legal documents, the legal
documents will govern.
For more detailed information on the plans and your legal rights under the plan, be sure to read the summary plan
descriptions or request a copy of the plan documents. All benefit plans are subject to change and Chestnut Hill College
reserves the right to amend or cancel any benefits described in this booklet, with or without notice. This document does
not guarantee benefits.
INTRODUCTION
We are pleased to provide you with this opportunity to participate in the Chestnut Hill College Employee Benefits Programs. We are very proud of our plans; please take a moment to review this Guide carefully.
Briefly, our employee "benefits plan year" is December 1st through November 30th. As an eligible employee, you will make your elections for the "benefits plan year" which ends every November 30th.
Eligibility:
• All full time employees are eligible for medical, dental and vision on the first day of employment. Coverage will commence on your hire date if it is the first of the month, or on the first of the month following your hire date.
• Once you have been an employee for 1 year you are eligible for Basic Life Insurance and Long Term Disability at no expense to you.
Contributions:
Your contributions to our medical, dental and vision plans are on a pre-tax basis, which is a significant advantage and cost savings for each employee. The federal government allows this pre-tax contribution but makes it clear that after you've made your annual election, you can only change your pre-tax election (medical and dental) if you have a qualified "Life Event".
Life Events/Mid-Year Changes:
A life event is defined below (by the IRS). If you experience a "Life Event" you have 30 days to notify HR of your requested change.
� a change in legal marital status
� a change in the number of dependents
� a change in you, your spouse's or your dependent's employment status
� a dependent satisfies or ceases to satisfy eligibility requirements
� a change in your, your spouse's or dependent's place of residence or the commencement or termination of an adoption proceeding.
Please review this "Employee Benefits Guide" carefully. This guide has been designed as an easy
read and includes a lot of important information. Thank you for taking the time to read this
information. If you need assistance beyond that feel free to contact the Human Resources
Department at 215-753-3674.
TUITION BENEFITS
Tuition Grant
All full time employees who are employed for at least 3 months can take up to two courses per semester. (total of 6 courses for the year). Dependents of employees may also qualify for tuition benefits. (see below for eligibility)
Employee Eligibility for Dependent Tuition Tuition Grant
Full Time, employed 90 days or longer and hired prior to 7/1/2002
100%
Full Time, hired 7/1/2002 or after, up to 1 year of employment
None
Full Time, hired 7/1/2002 or after, after 1 year of employment
25%
Full Time, hired 7/1/2002 or after, after 2 years of employment
50%
Full Time, hired 7/1/2002 or after, after 3 years of employment
75%
Full Time, hired 7/1/2002 or after, after 4 years of employment
100%
MEDICAL/PRESCRIPTION BENEFITS PLAN
FEATURES
HMO QPOS Choice POS
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK
OUT-OF-NETWORK
Deductible (per calendar year)
None Individual None Individual $1,000 Individual
None Individual
$1,000 Individual
None Family None Family $3,000 Family None Family $3,000 Family
Unless otherwise indicated, the deductible must be met prior to benefits being payable.
Applicable covered expenses accumulate separately toward the in-network and out-of-network providers Deductible.
Member cost sharing for certain services, as indicated in the plan, is excluded from charges to meet the Deductible. Pharmacy expenses do not apply towards the Deductible.
Out-of-Pocket Maximum (per calendar year)
$1,500 Individual
$1,500 Individual
$3,000 Individual
$1,500 Individual
$3,000 Individual
$3,000 Family $3,000 Family $9,000 Family $3,000 Family $9,000 Family
Member cost sharing for certain services may not apply toward the Out-of-Pocket Maximum.
All applicable covered expenses accumulate separately toward the in-network and out-of-network Out-of-Pocket-Maximum.
In-network expenses include coinsurance/copays and deductibles. Out-of-network expenses include coinsurance, deductible and copays. Penalty amounts do not apply.
Pharmacy expenses do not apply towards the Out-of-Pocket-Maximum.
Lifetime Maximum
Unlimited except where otherwise indicated.
Unlimited except where otherwise indicated.
Unlimited except where otherwise indicated.
Unlimited except where otherwise indicated.
Unlimited except where otherwise
indicated.
Benefit Limitations -- For any service or supply that is subject to a maximum visit, day, or dollar limitation, such services or supplies accumulate toward both the participating provider and non-participating provider benefit
limits under this plan.
Primary Care Physician Selection
Required Required Not Applicable Optional Not Applicable
Precertification Requirement Certain non-participating providers/participating provider self referred services require precertification or benefits will be reduced. Refer to your plan documents for a complete list of services
that require precertification.
Referral Requirement
Required Required None None None
PREVENTIVE CARE
Routine Adult Physical Exams/ Immunizations
Covered 100% Covered 100% Not Covered Covered 100%
Not Covered
1 visit every 12 months for ages 22 and older.
PLAN
FEATURES
HMO QPOS Choice POS
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK
OUT-OF-NETWORK
Routine Well Child Exams/Immunizations
Covered 100% Covered 100% 20%;
deductible waived
Covered 100%
20%; deductible waived
(Age and frequency schedules apply)
Routine Gynecological Care Exams
Covered 100% Covered 100% 20%;
deductible waived
Covered 100%
20%; deductible waived
1 exam per 12 months
Includes routine tests and related lab fees.
Routine Mammograms
Covered 100% Covered 100% 20%; after deductible
Covered 100%
20%; after deductible
Recommended: one annual mammogram for covered females age 40 and over.
Women's Health Covered 100% Covered 100% 20%; after deductible
Covered 100%
20%; after deductible
Routine Digital Rectal Exams / Prostate Specific Antigen Test
Covered 100% Covered 100% Not Covered Covered 100%
Not Covered
Recommended for males age 40 and over.
Colorectal Cancer Screening
Covered 100% Covered 100%
Member cost
sharing is based
on the type of
service
performed and
the place of
service where it
is rendered;
after deductible
Covered 100%
Member cost
sharing is based on
the type of service
performed and the
place of service
where it is rendered;
after deductible
For all members age
50 and over.
Frequency schedule applies.
PLAN
FEATURES
HMO QPOS Choice POS
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK
OUT-OF-NETWORK
Routine Eye Exams
Covered 100%
Direct access
to participating
providers
without a
referral.
Covered 100% Not Covered Covered 100% Not Covered
Routine Hearing Screening
Subject to Routine Physical
Exam benefit.
Subject to Routine Physical
Exam benefit.
Subject to Routine
Physical Exam
benefit.
Subject to Routine
Physical Exam
benefit.
Subject to Routine Physical Exam
benefit.
PHYSICIAN SERVICES
Office Visits to member's selected
Primary Care
Physician
Office Hours:
$15 copay; After
Office
Hours/Home:
$20 copay
Office Hours:
$20 copay; After
Office
Hours/Home:
$25 copay
20%; after deductible
Office Hours:
$25 copay;
After Office
Hours/Home:
$30 copay
20%; after deductible
Specialist Office Visits
$15 copay $20 copay 20%; after deductible
$25 copay 20%; after deductible
Maternity Delivery
and Post Partum
Care
$15 copay for initial visit only;
thereafter
covered 100%
$20 copay for initial visit only;
thereafter
covered 100%
20%; after deductible
$25 copay for initial visit only;
thereafter
covered 100%
20%; after deductible
Diagnostic Laboratory
Covered 100% Covered 100% 20%; after deductible
Covered 100% 20%; after deductible
If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable
physician's office visit member cost sharing.
Diagnostic X-ray $15 copay $20 copay 20%; after deductible
$25 copay 20%; after deductible
Outpatient hospital or other Outpatient facility (other than Complex Imaging Services)
Diagnostic X-ray for Complex
Imaging Services $15 copay $20 copay
20%; after deductible
$25 copay 20%; after deductible
PLAN
FEATURES
HMO QPOS Choice POS
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK
OUT-OF-NETWORK
EMERGENCY MEDICAL CARE
Emergency Room $100 copay $100 copay
Refer to participating
provider
benefit.
$100 copay Refer to
participating provider
benefit.
Emergency Use of
Ambulance Covered 100% Covered 100%
Refer to participating
provider
benefit.
Covered 100% Refer to
participating provider
benefit.
HOSPITAL CARE
Inpatient Coverage
$1,000 per admission
$1,000 per admission
20% per admission; after
deductible
$1,000 per admission
20% per admission;
after deductible
Outpatient Hospital
$200 per visit $200 per visit 20% per visit; after deductible
$200 per visit 20% per visit; after
deductible
MENTAL HEALTH SERVICES
Inpatient Mental Illness
$1,000 per admission
$1,000 per admission
20% per admission; after
deductible
$1,000 per admission
20% per admission;
after deductible
Outpatient Mental Illness
$15 per visit $20 per visit 20% per visit; after deductible
$25 per visit 20% per visit; after
deductible
ALCOHOL/DRUG ABUSE SERVICES
Inpatient Detoxification
$1,000 per admission
$1,000 per admission
20% per admission; after
deductible
$1,000 per admission
20% per admission;
after deductible
Outpatient Detoxification
$15 per visit $20 per visit 20% per visit; after deductible
$25 per visit 20% per visit; after
deductible
Inpatient Rehabilitation
$1,000 per admission
$1,000 per admission
20% per admission; after
deductible
$1,000 per admission
20% per admission;
after deductible
Outpatient Rehabilitation
$15 per visit $20 per visit 20% per visit; after deductible
$25 per visit 20% per visit; after
deductible
PLAN
FEATURES HMO QPOS Choice POS
PRESCRIPTION DRUG BENEFITS
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK
OUT-OF-NETWORK
Retail
$10 copay for formulary
generic drugs,
$20 copay for
formulary brand-
name drugs, and
$35 copay for
non-formulary
brand-name and
generic drugs up
to a30 day
supply at
participating
pharmacies.
$15 copay for formulary
generic drugs,
$25 copay for
formulary brand-
name drugs, and
$40 copay for
non-formulary
brand-name and
generic drugs up
to a 30 day
supply at
participating
pharmacies.
Not Covered
$15 copay for formulary
generic drugs,
$25 copay for
formulary
brand-name
drugs, and $40
copay for non-
formulary
brand-name and
generic drugs
up to a 30 day
supply at
participating
pharmacies.
Not Covered
Mail Order
$20 copay for formulary
generic drugs,
$40 copay for
formulary brand-
name drugs, and
$70 copay for
non-formulary
brand-name and
generic drugs up
to a31-90 day
supply from
Aetna Rx Home
Delivery®.
$30 copay for formulary
generic drugs,
$50 copay for
formulary brand-
name drugs, and
$80 copay for
non-formulary
brand-name and
generic drugs up
to a 31-90 day
supply from
Aetna Rx Home
Delivery®.
Not Covered
$30 copay for formulary
generic drugs,
$50 copay for
formulary
brand-name
drugs, and $80
copay for non-
formulary
brand-name and
generic drugs
up to a 31-90
day supply from
Aetna Rx
Home
Delivery®.
Not Covered
GUARDIAN VISION In-Network Eye Exams $10 copay Frequency Once per 12 months Lenses (Glasses) $25 copay* Frequency Once per 12 months Single Vision 100% after copay Lined Bifocal 100% after copay Lined Trifocal 100% after copay Lenticular 100% after copay Contact Lenses* $25 copay Frequency Once per 12 months Medically Necessary (contact lenses) 100% after copay Elective (contact lens)** $60 allowance Evalution and Fitting 15% discount of UCR Frames $25 copay Frequency Once per 24 months Fashion Frames* $60 allowance
* One copay for lenses and frames
*If you choose contact lenses, you will not be eligible to receive lenses for 12 months and a frame for 24 months
following the date contacts were obtained.
* Frames from Davis’ Fashion collection are covered in full in excess of this plan’s materials copay.
Frames from Davis’ Designer Collection are covered in full in excess of a $15 copay applied in addition to the
plan’s materials copay. Frames from Davis’ Premier collection are covered in full in excess of a $40 copay applied in
addition to the plan’s materials copay.
* Frames from a Davis network provider that are not in the collections are covered up to the plan’s retail
allowance in excess of the plan’s materials copay with a 20% discount on the amount over the $60 allowance for
frames.
** In-network elective contact lenses are covered up to the plan’s retail allowance in excess of the plan’s materials
copay with a 15% discount on the amount over $60 for contact lenses.
For more details please refer to the Guardian employee booklet.
To find a provider go to under Contacts click on "find a provider." Choose the Davis Vision Network to locate participating vision providers.
GUARDIAN DENTAL
Plan Provisions Core PPO Plan Buy-up PPO Plan
Deductible- (single/family) $50/$150 $50/$150
Calendar Year Maximum $1,250 per person $1,250 per person
THE PLAN PAYS In-Network Out-of-Network* In-Network Out-of-Network*
Diagnostic/Preventive 100%, no deductible 100%, no deductible
100%, no deductible 100%, no deductible
Basic Services 80%, after deductible
80%, after deductible
80%, after deductible 80%, after deductible
Major Services 0% (discounts available)
0% (discounts available)
50%, after deductible 50%, after deductible
Orthodontics 0% (discounts available)
0% (discounts available)
50%, no deductible 50%, no deductible
Orthodontic Lifetime Maximum
0% (discounts available)
0% (discounts available)
$1,000 per person
Maximum Rollover Feature • If you are enrolled in the BUY-UP PPO plan you have access to this feature.
• This feature allows employees to roll over a portion of their unused annual maximum into their personal Maximum Rollover Account (MRA). The MRA can be used in future years, if a member reaches the plan’s annual maximum.
• With a $1,250 maximum, assuming that an employee has not reached the threshold of $600 in paid claims during the benefit year, they will be eligible for $300 in their MRA for use in the following benefit year ($450 if using network dentists).
Plan Annual Maximum
Threshold Maximum Rollover Amount
In-Network Only Maximum Rollover Amount
Maximum Rollover Account Limit
$1,250 $600 $300 $450 $1,250
*If you chose a provider out of network, the out of network charge will be paid up to the maximum fee level established for The Guardian contracted providers. You are responsible for the amount above the fee schedule.
GUARDIAN LIFE, AD&D AND LONG TERM DISABILITY
BASIC LIFE/AD&D 1 TIMES BASE ANNUAL SALARY TO $200,000 MAXIMUM
VOLUNTARY TERM LIFE*
EMPLOYEE LIFE OPTIONS INCREMENTS OF $10,000 TO $500,000 MAXIMUM
GUARANTEE ISSUE AMOUNT
$150,000
SPOUSE LIFE OPTIONS 50% OF EMPLOYEE ELECTION TO $10,000
GUARANTEE ISSUE AMOUNT
$10,000
CHILD LIFE OPTIONS 10% OF EMPLOYEE ELECTION TO $10,000
GUARANTEE ISSUE AMOUNT
$10,000
ADDITIONAL BENEFITS WAIVER OF PREMIUM, PORTABILITY, ACCELERATED LIFE BENEFITS,
CONVERSION, SEATBELT/AIRBAG
GUARANTEE ISSUE (GI)
GUARANTEE ISSUE (GI) MEANS THAT COVERAGE CAN BE ELECTED UP TO A SPECIFIC LEVEL WITHOUT SUBMITTING AN EVIDENCE OF INSURABILITY FORM WHICH HAS HEALTH RELATED QUESTIONS. WITH THIS EMPLOYEE BENEFIT THE GI OFFERING ONLY OCCURS ONE TIME, THE FIRST TIME THE
BENEFIT IS OFFERED TO THE EMPLOYEE AND DEPENDENTS. IF THE EMPLOYEE (OR DEPENDENT) DECLINES COVERAGE INITIALLY AND ELECTS
IT AT A LATER DATE AN EVIDENCE OF INSURABILITY FORM WILL BE REQUIRED.
LONG TERM DISABILITY
ELIMINATION PERIOD 90 DAYS
MONTHLY BENEFIT 60% SALARY
MAXIMUM MONTHLY BENEFIT
$10,000
DURATION OF BENEFIT SOCIAL SECURITY NORMAL RETIREMENT AGE
DEFINITION OF DISABILITY
FOR THE FIRST 2 YEARS THE INABILITY TO PERFORM THE DUTIES OF YOUR JOB
AFTER 2 YEARS THE INABILITY TO DO ANY JOB BASED ON EDUCATION, TRAINING, AND PRIOR WORK EXPERIENCE
*Contact the Human Resources Department for specialized enrollment form if interested in this voluntary benefit.
VOLUNTARY BENEFITS
(ELECT ONLY 1 TIME PER YEAR) You may be eligible to apply for supplemental insurance. Participation in these benefits is voluntary. The advantages of the benefits being offered include:
• Competitive rates based on purchasing through a group.
• Relaxed underwriting requirements to qualify for coverage.
• The option to take policies with you if you change jobs or retire.
• The opportunity to provide coverage for you and your family.
• The convenience of premium payment through payroll deduction. You must meet with a benefits counselor to enroll.
Long Term Care used to fund nursing home expenses and home health care services. Provided by Genworth
Financial and/or John Hancock Financial Services.
Interest-Sensitive Whole Life Insurance can be used to help you meet long-term financial
goals. Provided by Provident Life and Accident Ins. Co. (“Provident”).
Accident Insurance is designed to help you meet those out-of-pocket expenses and
extra bills that can follow even ordinary accidents. Provided by Provident.
Critical Illness Insurance pays a lump sum benefit up to 100% of the face amount if diagnosed with a
covered critical illness including heart attack, stroke, etc. Provided by Provident.
Voluntary Short Term Disability pays up to 60% of weekly earnings in the event of a disability. Fully
portable and tax free. Provided by Provident.
If you are interested in any of the benefits enumerated above, please contact the Human Resources
Department for specialized enrollment forms.
FLEXIBLE SPENDING ACCOUNTS
ADMINISTERED BY GUARDIAN
Healthcare Spending Account:
How this works: Employee's can set aside pre-tax dollars to pay for out of pocket
"healthcare related" expenses incurred by the employee and/or dependents that would typically be paid with after tax dollars. The IRS determines the guidelines for this account.
Contribution: Maximum of $2,500 annually
Examples of Eligible Expenses • Medical, dental, vision plan co-pays or coinsurance
• Medical, dental, vision expenses not covered by insurance • Hearing aid expenses not
covered by insurance
• Vision expenses not covered by insurance
Examples on Non-eligible Expenses
• Over the counter expenses are no longer covered unless prescribed by a physician
• -Cosmetic related unreimbursed healthcare expenses
• Vitamins for general well being
• Teeth whitening
Dependent Care Spending Account:
How this works: Employee's can set aside pre-tax dollars to pay for out of pocket
"dependent care related" expenses incurred by the employee that would typically be paid with after tax dollars. The IRS determines the guidelines for this account.
Contribution: Maximum of $5,000 annually
For Healthcare and Dependent Care Spending Accounts:
Grace Period: Participants have 2 ½ months following the end of the plan year to incur eligible expenses which
can be reimbursed from available amounts that were remaining at the end of the previous plan year.
Run-out Period: Participants have 90 days after the end of the plan year, beginning December 1st, to submit
claims for eligible expenses that were incurred during the plan year or during the Grace Period.
*Please consult the Guardian Benefits Guide on our website for additional information.
GUARDIAN NURSES
Chestnut Hill College and Gallagher Benefit Services offer you Guardian Nurses services; peace of mind is just a phone call away. Call Guardian Nurses and they’ll do the rest — at no cost to you! Here’s how our Nurse Advocates can help: • BE YOUR GUIDE and advocate during hospitalizations or nursing home stays.
• DO THE RESEARCH so you have reliable information about treatment options.
• EXPLAIN EVERYTHING so you can make the best possible decisions.
• MAKE APPOINTMENTS to get you seen quickly, and go with you if requested.
• IDENTIFY PROVIDERS for elder services and long-term care placements.
• GET THINGS YOU NEED such as healthcare equipment and supplies.
• RESOLVE PROBLEMS with billing, claims and insurance.
• COACH YOU to better manage chronic health conditions.
Local Phone: 215.836.0260
Toll Free: 888.836.0260
Email: [email protected]
Website: www.guardiannurses.com
MONTHLY CONTRIBUTIONS
12/1/2013 THROUGH 11/30/2014
Aetna HMO
Eff. 12/1/13
Employee $0.00
w/Child(ren) $458.62
w/ Spouse $759.68
w/ Family $1,133.71
Aetna QPOS
Eff. 12/1/13
Employee $0.00
w/Child(ren) $460.28
w/ Spouse $762.74
w/ Family $1,137.29
Aetna Choice POS
Prior 12/02 Aetna Choice POS
After 12/02
Eff. 12/1/13 Current
Employee $0.00 $90.45
w/Child(ren) $530.85 $621.39
w/ Spouse $879.34 $969.88
w/ Family $1,311.25 $1,401.78
GUARDIAN VISION
Current
Employee $4.85
w/Child(ren) $8.16
w/ Spouse $8.32
w/ Family $13.16
GUARDIAN DENTAL
CORE PLAN BUY-UP PLAN
Employee $22.09 $32.80
w/Child(ren) $54.23 $95.41
w/ Spouse $48.57 $70.52
w/ Family $80.75 $133.18
Required Annual Employer Health Plan Notifications
HIPAA Special Enrollment Rights
A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in
the plan under its "special enrollment provision" if you acquire a new dependent, or if you decline coverage under this
plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain
qualifying reasons.
Loss of Other Coverage (Excluding Medicaid or a State Children's Health Insurance Program). If you decline enrollment
for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan
coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose
eligibility for that other coverage (or if the employer stops contributing toward your or your dependents' other
coverage). However, you must request enrollment within 30 days after your or your dependents' other coverage ends
(or after the employer stops contributing toward the other coverage).
Loss of Coverage for Medicaid or a State Children's Health Insurance Program. If you decline enrollment for yourself or
for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children's health
insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your
dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or
your dependents' coverage ends under Medicaid or a state children's health insurance program.
New Dependent by Marriage, Birth, Adoption, or Placement for Adoption. If you have a new dependent as a result of
marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents.
However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
Eligibility for Medicaid or a State Children's Health Insurance Program. If you or your dependents (including your
spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children's health
insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in
this plan. However, you must request enrollment within 60 days after your or your dependents' determination of
eligibility for such assistance.
To request special enrollment or obtain more information, contact Human Resources Department at 215-248-7036.
Women’s Health And Cancer Rights Act
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health
and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be
provided in a manner determined in consultation with the attending physician and the patient, for:
• All states of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses; and
• Treatment of physician complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and
surgical benefits provided under the plan.
If you have questions about the current plan coverage, please contact Human Resources Department at 215-248-7036.
Michelle’s Law
Michelle's Law requires group health plans to provide continued coverage for dependent children who are covered
under Chestnut Hill College’s group medical or dental plan as a student if they lose their student status because they
take a medically necessary leave of absence from school. This new law will apply to medically necessary leaves that
begin on or after January 1, 2010. This continuation of coverage is described below.
If your child is no longer a student, as defined in the plan, because he/she is on a medically necessary leave of absence,
your child may continue to be covered under the plan for up to one year from the beginning of the leave of absence.
This continued coverage applies if, immediately before the first day of the leave of absence, your child was (1) covered
under the plan and (2) enrolled as a student at a post-secondary educational institution (includes colleges, universities,
some trade schools and certain other post-secondary institutions).
For purposes of this continued coverage, a “medically necessary leave of absence” means a leave of absence from a
post-secondary educational institution, or any change in enrollment of the child at the institution, that:
• begins while the child is suffering from a serious illness or injury,
• is medically necessary, and
• causes the child to lose student status for purposes of coverage under the plan.
The coverage provided to dependent children during any period of continued coverage:
• is available for up to one year after the first day of the medically necessary leave of absence, but ends earlier if
coverage under the plan would otherwise terminate, and
• stays the same as if your child had continued to be a covered student and had not taken a medically necessary leave of
absence.
If the coverage provided by the plan is changed under the plan during this one-year period, the plan will provide the
changed coverage for the dependent child for the remainder of the medically necessary leave of absence unless, as a
result of the change, the plan no longer provides coverage for dependent children.
If you believe your child is eligible for this continued coverage, the child’s treating physician must provide a written
certification to the plan stating that your child is suffering from a serious illness or injury and that the leave of absence
(or other change in enrollment) is medically necessary.
Coordination with COBRA Continuation Coverage
If your child is eligible for Michelle's Law's continued coverage and loses coverage under the plan at the end of the
continued coverage period, continuation coverage under COBRA may be available at the end of Michelle's Law coverage
period and a COBRA notice will be provided at that time.
If you have any questions regarding the information in this notice or your child’s right to Michelle's Law continued
coverage you should contact your Renfrew HR Coordinator.
Automatic/Evergreen Elections
The Chestnut Hill College has an “Annual Election Period” during which you may enroll or change your elections for the
next plan year. The election that you make during the Annual Election Period is effective the first day of the next Plan
Year and cannot be changed during the entire Plan Year unless you have a Change in Status Event.
If you fail to enroll during the Annual Election Period, you may be deemed to have elected to continue participation in
the Chestnut Hill College Plan with the same Benefit Plan elections that you had on the last day of the Plan Year in which
the Annual Election period occurred (adjusted to reflect any increase/decrease in applicable premium/contributions).
Your FSA election will be defaulted to $0.
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer,
your State may have a premium assistance program that can help pay for coverage. These States use funds from their
Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance
through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these
premium assistance programs.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact
your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has
a program that might help you pay the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well
as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not
already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days
of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan,
you can contact the Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 1-866-444-EBSA
(3272).
If you live in one of the following States, you may be eligible for assistance paying your employer health
plan premiums. The following list of States is current as of July 31, 2013. You should contact your State
for further information on eligibility –
ALABAMA – Medicaid COLORADO – Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-855-692-5447
Medicaid Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943
ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529
ARIZONA – CHIP FLORIDA – Medicaid Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437
Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268
GEORGIA – Medicaid Website: http://dch.georgia.gov/ Click on Programs, then Medicaid, then Health
Insurance Premium Payment (HIPP) Phone: 1-800-869-1150
IDAHO – Medicaid and CHIP MONTANA – Medicaid Medicaid Website: www.accesstohealthinsurance.idaho.gov Medicaid Phone: 1-800-926-2588 CHIP Website: www.medicaid.idaho.gov CHIP Phone: 1-800-926-2588
Website: http://medicaidprovider.hhs.mt.gov/clientpages/ clientindex.shtml Phone: 1-800-694-3084
INDIANA – Medicaid NEBRASKA – Medicaid Website: http://www.in.gov/fssa Phone: 1-800-889-9949
Website: www.ACCESSNebraska.ne.gov Phone: 1-800-383-4278
IOWA – Medicaid NEVADA – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562
Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900
KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447
Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710
MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741
MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid
Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120
Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831
MINNESOTA – Medicaid NORTH CAROLINA – Medicaid
Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 1-800-657-3629
Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100
MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604
OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
Website: http://health.utah.gov/upp
Phone: 1-866-435-7414
OREGON – Medicaid and CHIP VERMONT– Medicaid
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov
Phone: 1-800-699-9075
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
Medicaid Website: http://www.dmas.virginia.gov/rcp-
HIPP.htm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.famis.org/
CHIP Phone: 1-866-873-2647
RHODE ISLAND – Medicaid WASHINGTON – Medicaid
Website: www.ohhs.ri.gov
Phone: 401-462-5300
Website:
http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm
Phone: 1-800-562-3022 ext. 15473
SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website: http://www.badgercareplus.org/pubs/p-
10095.htm
Phone: 1-800-362-3002
TEXAS – Medicaid WYOMING – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
Website:
http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any more States have added a premium assistance program since July 31, 2013, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
OMB Control Number 1210-0137 (expires 09/30/2013)
Notice of 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
Introduction
Chestnut Hill College Welfare Benefits Plan (the "Plan") is
required by law to maintain the privacy of your protected
health information. This Notice of Privacy Practices (the
“Notice”) applies to the medical, prescription and medical
spending account coverage offered through the Plan.
Protected health information is individually identifiable
health information that the Plan or its business associates
maintain or transmit in any form or medium, including verbal
conversations and written or electronic information.
Individually identifiable health information is information
that identifies you, or could reasonably be used to identify you,
and that relates to your past, present or future (a) physical or
mental health, (b) provision of health care, or (c) payment for
such health care.
The Plan’s Duties Regarding This Notice
The Plan must give you this Notice to explain the uses and
disclosures of your protected health information, to advise you
of your rights with respect to your protected health
information, and to explain the Plan's legal duties and privacy
practices with respect to your protected health information.
The Plan is required to abide by the terms of the Notice
currently in effect. The Plan reserves the right to change the
terms of this Notice and make the new provisions applicable to
all protected health information that it maintains. In the event
the Plan changes this Notice in a significant manner, the Plan
will distribute a revised notice.
The Plan is meeting its obligation by delivering this Notice to
you. This Notice is effective April 14, 2004.
How Your Protected Health Information May Be Used or Disclosed
For Treatment, Payment, and Health Care Operations
The confidentiality of your protected health information is very important to us. The Plan is able to use or disclose your protected health information for treatment, payment, and health care operations as explained below. Other uses and disclosures of your protected health information are explained in later sections of this Notice.
Treatment Treatment means the provision, coordination, or management of health care and related services by one or more health care providers. For example, the Plan may disclose, for treatment purposes, protected health information to a health care provider such as a physician, pharmacist, or dentist involved in your care.
Payment The Plan may use or disclose your protected health information for purposes relating to payment. Payment includes activities such as:
• Determining eligibility for coverage,
• Obtaining premium payments for the coverage,
• Performing utilization review of services (including pre-certification or preauthorization),
• Coordinating benefits with other health plans,
• Applying for reimbursement under a reinsurance contract,
• Reviewing your claim for health care services, and
• Making a determination as to whether the claim is a covered benefit and is payable by the Plan.
For example, you or your health care provider may submit your claim to the Plan for payment. This claim will contain information that identifies you, and may include the date the service took place, the diagnosis, the treatment provided, and the charges. The Plan uses this information to evaluate the medical necessity of the treatment and to determine its payment obligation under the terms of the Plan. Also, if you are covered by another health plan, such as through your spouse’s employer, the Plan may disclose your claim information to the other plan to determine which plan has primary payment responsibility and to coordinate any benefits due.
Health Care Operations The Plan may use or disclose protected health information for the management and oversight of its health care operations. Health care operations include many activities such as:
• Activities that relate to quality and accreditation (including quality assessment and improvement, assessment of outcomes, accreditation by independent organizations, and review of qualifications of health care professionals);
Health Care Operations (Continued) • Cost, underwriting, and contract placements (including
determining the current and projected costs of the Plan, cost-management reviews, obtaining premium quotes, and activities relating to the creation, renewal, or replacement of a health insurance contract or reinsurance contract);
• Medical review and care coordination (including contacting Plan members or health care professionals with information about treatment, review (such as for claim appeals), case management, and other care coordination); and
• Legal oversight (including legal services provided to the Plan, auditing, and fraud and abuse detection).
The Plan may use your protected health information to contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you An example of medical review is the Plan’s formal process to respond to claim appeals. Upon appeal, your relevant protected health information such as the treatment provided and your diagnosis will be gathered and reviewed by persons (including, if appropriate, a health care professional) other than the person who made the initial decision. If necessary, the Plan may also contact your health care provider for additional information regarding your appealed claim.
Other Information The Plan will take reasonable steps and apply safeguards to limit the permitted or required uses and disclosures of your protected health information to the minimum amount necessary to accomplish the task. With these protections in place, a use or disclosure that is incidental to a permitted or required use or disclosure is allowed. If a state law has more privacy protections than the federal law, called the Health Insurance Portability and Accountability Act (HIPAA), that governs privacy, then the Plan will abide by the state law in those instances. State laws may permit minors to obtain certain medical care without a parent’s permission or knowledge and the Plan will follow those state laws as applicable. The descriptions listed above do not include every possible use or disclosure that is permitted or required by law. The descriptions given are only intended to provide you with information about the various ways that the Plan may use or disclose your protected health information and to give you some examples.
Other Permitted or Required Uses and Disclosures Other than treatment, payment, and health care operations, the Plan is permitted or required by law to use or disclose your protected health information in other ways described below.
To You or Certain Other Individuals Your own protected health information may be disclosed to you or to your personal representative who is an individual, under applicable law, authorized to make health care decisions on your behalf. For example, a parent is generally the personal representative of a minor child.
The Plan may disclose your protected health information to a family member, other relative, close personal friend or other person identified by you. The protected health information that is disclosed must be directly relevant to the family member or other person’s involvement with your health care or payment for your health care. The requirements are that you must be present or available prior to the use or disclosure and (a) agree, (b) have the opportunity to object, or (c) the Plan
may determine, based on the circumstances and its professional judgment, to make the disclosure.
Unless you object, the Plan may confirm eligibility status (coverage under the Plan) and claim status information (limited to confirmation that the claim was received and paid or not paid) to a family member who calls with knowledge of the claim. You may specifically request that the Plan not disclose this eligibility status and claim status information by contacting the Privacy Officer. If you are not present or are incapacitated, the Plan may use its professional judgment to determine whether the disclosure of protected health information is in your best interests. If the Plan makes this determination, it may disclose only your protected health information that is directly relevant to the individual's involvement with your health care.
The Plan may, in certain situations, use or disclose your protected health information to notify, or assist in notifying, a family member,
personal representative, or other person involved in your care of your location or condition.
To Business Associates The Plan works with different organizations that perform a variety of services on its behalf. These organizations, or Business Associates, perform specific functions and services for the Plan. Examples of functions include claim processing, utilization review, plan administration, and data analysis. Services include consulting, legal, financial, and management activities.
The Plan may disclose protected health information to its Business Associates for the permitted functions or services, but only if the Plan receives assurances through a written contract or agreement that the Business Associate will properly safeguard the information.
To the Plan Sponsor Protected health information may be disclosed to the plan sponsor for plan administrative functions. Before doing so, the terms of the Plan must establish, in accordance with the privacy regulations, the permitted and required uses or disclosures of the information and protections for the information. Summary Health Information used for certain purposes and information about who is participating in the Plan may be disclosed to the plan sponsor without any special Plan provisions. Summary Health Information is claims information from which individual identifiers have been removed, except for the five-digit zip code.
In A Limited Data Set A limited data set contains protected health information from which direct identifiers such as name and social security number have been removed, but indirect identifiers such as date of service have been kept. Information in a limited data set may be used or disclosed for research, public health, or health care operations. The information may be disclosed only if the Plan has entered into an agreement with the recipient that establishes its permitted uses or disclosures.
As Required by Law and for Public Benefit Protected health information may be:
• Used or disclosed as required by law and in compliance with the requirements of the law, including disclosures to the Secretary of Health and Human Services for the
purpose of determining compliance with the privacy standards;
• Disclosed to an authorized public health authority for specified reasons such as to prevent or control disease, injury, or disability; to report child abuse or neglect; to report the safety or effectiveness of FDA-related products such as medication; and to notify a person at risk of contracting or spreading a communicable disease;
• Disclosed to an authorized government authority if the disclosure is about victims of abuse, neglect, or domestic violence;
• Disclosed to authorized health oversight agencies for activities such as audits, investigations, inspections, and licensure requirements necessary for oversight of the health care system and various government benefit programs;
• Disclosed for judicial and administrative proceedings such as responses to court orders and court-ordered warrants, to subpoenas issued, to discovery requests, or other lawful processes;
• Disclosed to a law enforcement official for a law enforcement purpose;
• Disclosed to coroners or medical examiners for purposes of identifying a deceased individual and to funeral directors to carry out their duties;
• Used or disclosed to an organ and tissue procuring or transplanting organization to facilitate donation and transplantation;
• Used or disclosed for research purposes if certain requirements are met such as approval by an Institutional Review Board or a Privacy Board;
• Used or disclosed as necessary to prevent or lessen a serious or imminent threat to the health and safety of a person or the public;
• Disclosed to comply with workers’ compensation or other similar laws; and
• Disclosed to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.
For Specialized Government Functions Protected health information may be disclosed to federal officials for national security reasons. Protected health information may be used or disclosed to military authorities about Armed Forces personnel for certain purposes. The Plan may release protected health information to a correctional institution for provision of health care to the individual or for the health and safety of the individual or others.
Other Uses and Disclosures Only in Accordance with Your Authorization Other than the uses or disclosures of your protected health information that are permitted or required by law, the Plan may not use or disclose your protected health information unless you authorize the Plan to do so by completing a written authorization. You may revoke your authorization at any time to stop future uses or disclosures; however, the revocation will not apply to the extent that the Plan has already made uses or disclosures in reliance on your authorization. Your revocation will also not be effective to the extent that the authorization was given as a condition of obtaining insurance coverage if
another law gives the insurer the right to contest a claim under the policy or the right to contest the policy itself.
Your Individual Rights Regarding Your Protected Health Information
You have certain rights with respect to your
protected health information, as described in detail
below. You may exercise your rights by submitting
a written request that specifies the right(s) you wish
to exercise. Requests should be sent to the
Contact Person for the Plan; contact information is
provided at the end of this Notice.
Right to Request Restrictions You have the right to request restrictions on certain uses or disclosures of your protected health information for the purposes of treatment, payment, or health care operations. The Plan is not required to agree to any restriction that you request. You will be notified if your request is accepted or denied.
Right to Receive Confidential Communications You have the right to request receipt of confidential communications of your protected health information from the Plan by reasonable alternative means or at an alternative location. The Plan is not required to honor your request unless you state that the disclosure of all or part of the information could endanger you.
Right to Inspect and Copy You have the right to inspect and copy your protected health information that is contained in a "designated record set", that is, enrollment, payment, claims determination, case or medical management records, or records that are used to make decisions about you and that are maintained by the Plan. The Plan may charge you for the reasonable costs associated with your request. There are some exceptions to your right to inspect and copy, such as:
• Psychotherapy notes,
• Information compiled in anticipation of a civil, criminal, or administrative action or proceeding, and
• Situations in which a licensed health care professional determines that releasing the information may have a harmful effect on you or another individual.
Right to Request an Amendment If you believe that protected health information about you that is contained in a "designated record set" is inaccurate or incomplete, you have the right to request
that it be amended. Your request must be in writing and you must provide a reason to support your request. The Plan may deny your request for an amendment if your request is not in writing or if you do not provide a reason for your request. Your request will also be denied if the Plan determines that:
• The information was not created by the Plan (unless you provide a reasonable basis to believe that the originator of the information is no longer available to act on your request),
• The information is not part of the "designated record set",
• Access to the information is restricted by law, or
• The information is accurate and complete. If your request is denied, you will receive written notification of the denial explaining the basis for the denial and a description of your rights.
Right to an Accounting of Disclosures You have the right to receive a listing of, or an accounting of, disclosures of your protected health information made by the Plan. Certain disclosures do not have to be included in this accounting, including the following:
• Those made for treatment, payment, or health care operations,
• Those made pursuant to your written authorization,
• Those made to you,
• Those that are incidental to otherwise permitted or required disclosures,
• Those made as part of a limited data set,
• Disclosures to individuals involved in your care, and
• Disclosures for certain security or intelligence reasons and to certain law enforcement officials.
If you request an accounting of disclosures of your protected health information, you will need to specify the dates you want the accounting to cover. The accounting period cannot exceed six years prior to the date of the request and it cannot cover a period prior to April 14, 2004. You are entitled to one free accounting in any 12-month period. The Plan may charge for any additional accountings you request within the same 12-month period. The Plan will notify you in advance of any charges.
Right to Receive a Paper Copy Even if you have agreed to receive this Notice electronically, you have the right to request and receive a paper copy of this Notice from the Plan.
Complaints and Contact Information Complaints If you are concerned that your privacy rights have been violated, you may submit a complaint to the Plan by contacting the Contact Person for the Plan. The complaint must be in writing and provide a description of why you think your privacy rights were violated. No retaliatory actions will be taken against you for filing a complaint.
You may also file a complaint with the Secretary of
Health and Human Services at:
Office for Civil Rights U.S. Department of Health and Human Services 150 S. Independence Mall West, Suite 372 Public Ledger Building Philadelphia, PA 19106-9111 Main Line (215) 861-4441 Hotline (800) 368-1019 Fax (215) 861-4431 TDD (215) 861-4440
Contact Please contact the Contact Person for the Plan in order to: • Obtain a paper copy or another copy of this
Notice; • Ask questions about this Notice or the Plan’s
practices regarding protected health information,
• File a complaint, • Request that disclosure of eligibility status or
claim status not be provided to a family member,
• Obtain an Authorization form, or • Make a request for individual rights as described
above. The phone number is: 215-248-7036.
The address is: HIPAA Compliance Officer, Benefits Administrator Chestnut Hill College 9601 Germantown Ave Philadelphia, PA 19118
