Rights & Protections
ERISA of 1974
As a participant in the District Council 16 Northern California Health and Welfare Trust Fund, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan Participants shall be entitled to:
- Examine, without charge, at the Plan Administrator’s office all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration (formerly known as the Pension and Welfare Benefit Administration).
- Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies.
- Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.
- Continue health care coverage for yourself, Spouse or Dependents if there is a loss of coverage under the Plan as a result of a Qualifying Event, as described in the COBRA chapter. You and/or your Dependents may have to pay for such coverage, if it is elected. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA Continuation Coverage rights.
- In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit Plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants and beneficiaries.
- No one, including your employer, your union, or any other person may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
- If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules, as discussed in the Claims Filing and Appeals Information chapter of this document.
- Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
- If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or Federal court. See the Plan’s Claims Filing and Appeal information on the requirement to appeal a denied claim and exhaust the Plan’s appeal process before filing a lawsuit.
- In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a medical child support order (QMCSO), you may file suit in Federal court.
- If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U. S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
- If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration (formerly known as the Pension and Welfare Benefit Administration), U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration (formerly known as the Pension and Welfare Benefit Administration), U.S. Department of Labor, 200 Constitution Avenue, N. W., Washington, DC 20210.
You may obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration (formerly known as the Pension and Welfare Benefit Administration) at Toll-Free: 1.866.444.EBSA (3272).
COBRA of 1985
Entitlement to COBRA Continuation Coverage
In compliance with a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (commonly called COBRA), eligible Employees, eligible Retirees and their covered Dependents (called “Qualified Beneficiaries”) will have the opportunity to elect a temporary continuation of their group health coverage (“COBRA Continuation Coverage”) under the Plan when that coverage would otherwise end because of certain events (called “Qualifying Events” by the law).
Alternatives to COBRA
Note that you may also have other health coverage alternatives to COBRA available to you that can be purchased through the Health Insurance Marketplace. Also, in the Marketplace you could be eligible for a tax credit that lowers your monthly premiums for Marketplace-purchased coverage. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit. For more information about the Health Insurance Marketplace, visit www.healthcare.gov. Also, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a Spouse’s plan), if you request enrollment in that plan within 30 days, even if that plan generally does not accept late enrollees.
Qualified Beneficiaries who elect COBRA Continuation Coverage must pay for it at their own expense.
This Plan provides no greater COBRA rights than what is required by law and nothing in this chapter is intended to expand a person’s COBRA rights.
Choosing Not to Elect COBRA
If you and/or your Dependents do not elect COBRA within the 60-day period allowed, you will forfeit all rights to COBRA continuation coverage and your health care coverage will end. If you are enrolled in the medical HMO, you may apply for an individual conversion policy.
In considering whether to elect COBRA continuation coverage, you should take into account that a failure to continue your group health coverage will affect your future rights under Federal law.
First, if you have a gap in health coverage of 63 days or more, you can lose the right to avoid having pre-existing condition exclusions applied to you by other group health plans (election of COBRA continuation coverage may prevent such a gap).
Second, if you do not get continuation coverage for the maximum time available to you, you will lose the guaranteed right to purchase individual health insurance policies that do not impose such pre-existing condition exclusions.
Finally, you have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your Spouse’s employer). Special enrollment under this provision is allowed within 30 days after your group health coverage ends because of the qualifying events listed above or at the end of COBRA continuation coverage if you get COBRA continuation coverage for the maximum time available to you.
California COBRA Law
If you are a COBRA Participant enrolled in the medical HMO Plan, California law has two provisions that affect the length of time you may continue coverage. These laws apply only to your medical HMO coverage, not to any other health care benefits usually available under COBRA.
If your Qualifying Event was low hours, termination of your employment, or retirement and you exhaust the 18 months of coverage normally available after such a Qualifying Event (or the 29 months available in the case of disability), you may continue your HMO coverage an additional 18 months (or an additional 7 months in the case of a disability). If this applies to you, you must contact the HMO directly to continue coverage.
To obtain complete information regarding COBRA Continuation of Coverage, refer to the Summary Plan Description (SPD)/Plan Document.
FMLA of 1993
If your employer approves your taking a leave under the terms of the Family and Medical Leave Act of 1993 (FMLA), you and your eligible Dependents will continue to be covered for medical, dental and vision benefits under the Trust Fund, provided you were eligible when the leave began and your employer makes the required contributions during your leave.
Coverage for these benefits will be continued while you are absent from work on an FMLA leave as if there were no interruption of active employment and as if you were continuing to work the number of hours required for coverage. This coverage will continue until the earlier of the expiration of the FMLA leave or the date you give notice to your employer that you do not intend to return to work at the end of the leave. If you do not return to work after the end of the FMLA leave, your employer may require you to reimburse him for the contributions made to the Trust Fund on your behalf during the leave.
It is not the role of the Trust Fund to determine whether or not an Employee is entitled to FMLA leave. Any disputes regarding entitlement to FMLA leave with continuing benefits must be resolved with your employer.
USERRA of 1994
Leave for Military Service/Uniformed Services Employment and Reemployment Rights Act (USERRA)
A participant who enters military service will be provided continuation and reinstatement rights in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended from time to time. This section contains important information about your rights to continuation coverage and reinstatement of coverage under USERRA.
What is USERRA? USERRA Continuation Coverage is a temporary continuation of coverage when it would otherwise end because the Employee has been called to active duty in the uniformed services. USERRA protects Employees who leave for and return from any type of uniformed service in the United States armed forces, including the Army, Navy, Air Force, Marines, Coast Guard, National Guard, National Disaster Medical Service, the reserves of the armed forces, and the commissioned corps of the Public Health Service.
An Employee’s coverage under this Plan will terminate when the Employee enters active duty in the uniformed services.
- If the Employee elects USERRA temporary continuation coverage, the Employee (and any eligible Dependents covered under the Plan on the day the leave started) may continue Plan coverage for up to 24 months measured from the date the Employee stopped working.
- Coverage will be continued under the Trust Fund during military service with a duration of less than 31 days. If you are an hourly bargaining Employee, your Cash Bank reserve will be credited with an amount equivalent to 8 hours per day of uniformed military service, up to 40 hours per week, during such service.
- Cash Bank. You have two options regarding your Cash Bank when you enter military service for 31 days or more. You may use your Cash Bank to continue your coverage (and your eligible Dependents’ coverage) until your Cash Bank is exhausted. Or, you may freeze your Cash Bank so the money will be available for coverage when you return. If you wish to freeze your Cash Bank, you must notify the Trust Fund Office in writing that you wish to freeze it within 15 days of the date you enter military service.
- Paying for up to 24 months of coverage. Once you have exhausted your Cash Bank, or if you chose to freeze your Cash Bank, you may continue benefits for yourself and your eligible Dependents under COBRA or for up to 24 months under USERRA by paying the required “self-payment” premiums. The rules regarding payment of USERRA premiums are similar to those for continuing coverage under COBRA. For more information about self-payments under USERRA, contact the Trust Fund Office.
- Duty to Notify the Plan: The Plan will offer the Employee USERRA continuation coverage only after the Trust Fund Office has been notified by the Employee in writing that they have been called to active duty in the uniformed services. The Employee must notify the Trust Fund Office (contact information is on the Quick Reference Chart) as soon as possible but no later than 60 days after the date on which the Employee will lose coverage due to the call to active duty, unless it is impossible or unreasonable to give such notice.
Plan Offers Continuation Coverage: Once the Trust Fund Office receives notice that the Employee has been called to active duty, the Plan will offer the right to elect USERRA coverage for the Employee (and any eligible Dependents covered under the Plan on the day the leave started). Unlike COBRA Continuation Coverage, if the Employee does not elect USERRA for the Dependents, those Dependents cannot elect USERRA separately. Additionally, the Employee (and any eligible Dependents covered under the Plan on the day the leave started) may also be eligible to elect COBRA temporary continuation coverage. Note that USERRA is an alternative to COBRA therefore either COBRA or USERRA continuation coverage can be elected and that coverage will run simultaneously, not consecutively. Contact the Trust Fund Office to obtain a copy of the COBRA or USERRA election forms. Completed USERRA election forms must be submitted to the Plan in the same timeframes as is permitted under COBRA.
In addition to USERRA or COBRA coverage, an Employee’s eligible Dependents may be eligible for health care coverage under TRICARE (the Department of Defense health care program for uniformed service members and their families). This Plan coordinates benefits with TRICARE. You should carefully review the benefits, costs, provider networks and restrictions of the TRICARE plan as compared to USERRA or COBRA to determine whether TRICARE coverage alone is sufficient or if temporarily continuing this plan’s benefits under USERRA or COBRA is the best choice.
After Discharge from the Armed Forces:
When the Employee is discharged from military service (not less than honorably), eligibility will be reinstated on the day the Employee returns to work provided the Employee returns to employment within:
- 90 days from the date of discharge from the military if the period of services was more than 180 days; or
- 14 days from the date of discharge if the period of service was 31 days or more but less than 180 days; or
- at the beginning of the first full regularly scheduled working period on the first calendar day following discharge (plus travel time and an additional 8 hours), if the period of service was less than 31 days.
If you are hospitalized or convalescing from an injury caused by active duty, these time limits are extended up to two years.
If you are seeking work in the jurisdiction of this Trust Fund, but are unable to find work, be sure to notify the Trust Fund Office within 90 days after your discharge or release from military service.
- If you froze your Cash Bank, you and your eligible Dependents’ coverage under this Trust Fund will resume on the first day of the month following the month you return from military service, provided you have enough money in your Cash Bank to cover at least one month of coverage.
- If your Cash Bank was exhausted during your military service or you do not have enough money in your Cash Bank, you and your eligible Dependents’ coverage under this Trust Fund will resume on the first day of the month following the month your Cash Bank is credited with enough to pay for one month of coverage.
If you are a monthly Employee, you and your Dependents’ coverage under this Trust Fund will resume the first day of the month for which your employer makes the required contributions. Questions regarding your entitlement to USERRA leave and to continuation of coverage should be referred to the Trust Fund Office.
HIPAA Privacy & Security
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.
Effective Date of Notice: November 1, 2016.
You have the right to:
- Get a copy of your health and claims records
- Correct your health and claims records
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
- Answer coverage questions from your family and friends
- Provide disaster relief
Our Uses and Disclosures
We may use and share your information as we:
- Help manage the health care treatment you receive
- Run our organization
- Pay for your health services
- Administer your health plan
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests and work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of health and claims records
- You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records
- You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations.
- We are not required to agree to your request, and we may say “no” if it would affect your care.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in payment for your care
- Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Psychotherapy notes
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Help manage the health care treatment you receive
We can use your health information and share it with professionals who are treating you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.
Run our organization
- We can use and disclose your information to run our organization and contact you when necessary.
- We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.
Example: We use health information about you to develop better services for you.
Pay for your health services
We can use and disclose your health information as we pay for your health services.
Example: We share information about you with your dental plan to coordinate payment for your dental work.
Administer your plan
We may disclose your health information to your health plan sponsor for plan administration.
Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.
Other Uses and Disclosures
Any other use or disclosure not described in the Notice will only be made with your authorization.
Revocation of Prior Authorization.
You may revoke a prior authorization granted for psychotherapy notes, marketing, sales or any other authorized use and disclosure.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests and work with a medical examiner or funeral director
- We can share health information about you with organ procurement organizations.
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Whom to Contact at the Plan for More Information
If you have any questions regarding this Notice or the subjects addressed in it, you may contact the Privacy Officer, specified below, at the Trust Fund Office:
Health Services & Benefit Administrators, Inc.
4160 Dublin Boulevard, Suite 400
Dublin, CA 94568-7756
Phone: (800) 922-9902 Fax: (925) 833-7301
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.
Explanation of Security Practices
In compliance with HIPAA Security regulations, the Plan Sponsor will:
- Implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of electronic PHI that it creates, receives, maintains or transmits on behalf of the group health plan,
- Ensure that the adequate separation discussed in Exhibit A, specific to electronic PHI, is supported by reasonable and appropriate security measures,
- Ensure that any agent, including a subcontractor, to whom it provides electronic PHI agrees to implement reasonable and appropriate security measures to protect the electronic PHI, and
- Report to the Plan any security incident of which it becomes aware concerning electronic PHI.
WHCRA of 1996
Women’s Health & Cancer Rights Act (WHCRA) and Newborns’ & Mothers’ Health Protection Act (Newborns’ Act)
This plan complies with the Women’s Health and Cancer Rights Act (WHCRA) that states for any covered individual who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with it, coverage will be provided in a manner determined in consultation with the attending physician and the patient, including:
- reconstruction of the breast on which the mastectomy was performed;
- surgery and reconstruction of the other breast to produce a symmetrical appearance; and
- prosthesis and physical complications for all stages of mastectomy, including lymphedemas.