This Summary Plan Description describes the Employee Assistance Program benefit available under the Franklin & Marshall College Group Long-term Disability Insurance Plan (the Employee Assistance Program benefit is described herein as the "Employee Assistance Program", the "Program", or the ”Plan”), effective as of July 1, 2013. This Summary Plan Description is required by The Employee Retirement Income Security Act (ERISA) of 1974, as amended. The purpose of this Summary Plan Description is to acquaint employees with the provisions of the Employee Assistance Program, the way in which it is administered, and participants' rights under the federal law which applies to employee benefit plans. Every effort has been made to make this Summary Plan Description as accurate as possible, however, in the event of a discrepancy between this Summary Plan Description and the Plan Document, the Plan Document shall control. The Plan Document can be viewed by contacting Human Resources. The Plan is established for the benefit of employees, their covered dependents, and their beneficiaries, and is administered impartially for the benefit of all eligible participants.
Facts About the Plan
Plan Name: Franklin & Marshall College Group Long-term Disability Insurance Plan (the"Employee Assistance Program")
Plan Number: 503 - Plan 503 also includes the Franklin & Marshall College Group Long-term Disability Insurance Plan and the Group Business Travel Accident Insurance Plan, which are each described in separate Summary Plan Descriptions.
Name, Address, and Telephone Number of Employer/Sponsor: Franklin & Marshall College, Lancaster, PA 17604-3003, (717) 291-3995. Employer shall also include the Lancaster City Alliance (effective February 25, 2003).
Plan Sponsor's Employer Identification Number: 23-1352635
Plan Year: July 1 through June 30
Type of Plan: Welfare Plan (Plan)
Plan Administrator: Franklin & Marshall College, P.O. Box 3003, Lancaster, PA 17604-3003
Plan Benefits Provided By: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company, 1777 Sentry Park West, Gwynedd Hall, Suite 100, Blue Bell, PA 19422, (215) 283-3947; administrative responsibilities assigned to Cigna Behavioral Health.
Agent for Service of Legal Process: Same as Plan Administrator
Funding: Fees for coverage through the Employee Assistance Program are paid by Franklin & Marshall College, through general employer assets. Enrolled "COBRA" participants pay fees.
Assessment, Counseling, and Referral
An eligible employee, and family members regularly residing in his/her household, may participate in up to three (3) phone or in-person sessions through the Employee Assistance Program per Plan Year, per issue. Services provided through the Employee Assistance Program include confidential assessment, and if deemed necessary by a Program counselor, counseling and referral services. Employees and/or eligible family members residing in the employee's household may contact the Employee Assistance Program provider, Cigna, to seek assessment, counseling, and/or referral services with regard to a personal, marital, or family-related concern; work-related concern; school-related concern; substance abuse issue; or any other concern for which the employee or family member would like assistance through the Program. There are no pre-existing condition exclusions. Use of the Employee Assistance Program is optional.
Assessment, counseling, and referral services are provided by counselors employed by Cigna, or by Cigna' contracted providers. Eligible employees and family members regularly residing in the employee's household must contact Cigna, at (877) 622-4327, in advance to access services provided through the Employee Assistance Program.
Assessment or counseling beyond three (3) sessions per Plan Year, per issue; psychological testing; career aptitude and placement services; outplacement counseling and services; and psychiatric services are services which are excluded under the Employee Assistance Program.
Employees and their dependents enrolled in the Franklin & Marshall Group Health & Prescription Drug Plan may be eligible for mental health treatment through that plan. The Summary Plan Description for the Group Health & Prescription Drug Plan and the Schedule of Benefits, available from Human Resources, contain details about mental health benefits.
Eligibility for Coverage
The following employees are eligible to participate in the Employee Assistance Program:
• full-time faculty and professional staff employees: Franklin & Marshall College employees who are scheduled to work at least 30 hours per week for wages on a regular basis, including visiting, tenured, non-tenured, and tenure-track faculty; full-time employees of the Lancaster City Alliance; and full-time employees of the Centennial Conference who: (1) are regularly scheduled to work on the Franklin & Marshall College campus and (2) are paid through the College's payroll system, as long as otherwise eligible
• full-time faculty and professional staff employees who are scheduled to work at least 30 hours per week for wages on an approved 9, 10, or 11 month per year appointment
• faculty on an approved joint appointment: one full-time position shared by two College faculty members each working at least 1040 hours annually
• full-time faculty working a reduced schedule under an approved Phased Retirement Agreement
• full-time faculty on an approved paid sabbatical or paid Junior Faculty Leave
• full-time faculty and professional staff employees on an approved paid or unpaid Family & Medical Leave as provided for in the Family & Medical Leave Act, or other approved leave of absence which provides for continued coverage
Independent contractors, contracted employees, adjunct faculty, individuals who volunteer their services without compensation, students, student employees, retired College employees, and those not in a covered class are not eligible to participate in the Employee Assistance Program.
Eligible Dependents for Purposes of the Employee Assistance Program
An eligible employee's family members who regularly reside with the employee in the employee's household are eligible to participate in the Employee Assistance Program. For purposes of the Program, eligible family members will typically include an employee's spouse or same-sex domestic partner, and children. Children include biological or legally adopted children, foster children, step-children, children for whom the employee is the legal guardian, and children of an employee's same-sex domestic partner who regularly reside with the employee, and/or who are claimed by the employee as legal dependents. An employee's dependent children who attend school or college, and as a result do not reside with the employee during the academic year, continue to be eligible to participate in the Program if they reside with the employee while school/college is not in session. Solely for purposes of the Employee Assistance Program, eligible dependents may include other members of an eligible employee's family, such as an opposite-sex domestic partner, parent, or sibling, if such family members regularly reside with the employee in the employee's household. Upon seeking benefits through the Program, the benefit provider, Cigna, may require verification of eligibility.
Eligibility for participation through the Employee Assistance Program is effective immediately upon appointment to a full-time position as a member of an eligible class. Eligible employees and their eligible dependents (family members regularly residing in the employee's household) are automatically enrolled in the Employee Assistance Program; there are no enrollment forms required. Eligible employees are not required to notify the Plan Administrator of their eligible dependents, however, when seeking benefits, the benefit provider, Cigna, may require verification of eligibility.
Eligibility for participation through the Program continues until an employee is no longer a member of an eligible class or until terminated as outlined below.
Employee Assistance Program costs are paid by Franklin & Marshall College from general employer assets. There are no fees or premiums required from eligible employees or their dependents.
Termination of Coverage
An eligible employee, and his/her eligible dependents, will cease to be eligible to participate in the Employee Assistance Program effective on the date one or more of the following events occurs:
1) employment termination, including retirement
2) loss of full-time employment status or other event which causes an employee to no longer be a member of an eligible class
3) death of an eligible employee
4) during a medical leave of absence: expiration of employer-paid sick leave benefits (salary continuation) or expiration of eligibility for Family & Medical Leave, whichever occurs later
5) an eligible employee's last work day prior to commencement of an unpaid leave of absence, including disability leave, other than an approved Family & Medical Leave or other approved leave of absence which provides for continued coverage
6) expiration of a leave of absence which provided for continued participation
Coverage will also end if Franklin & Marshall College fails to pay the required premium or terminates the Program.
Please see the “COBRA” section below for important information about optional, temporary continuation of coverage through the Plan following a “Qualifying Event” that leads to loss of coverage.
Benefit Denials and Claims Procedures
The Employee Assistance Program provider, Cigna, determines the level of assessment and counseling necessary for a participant, and when a referral for further treatment is necessary.
The Plan Administrator shall have the responsibility and authority, in its sole discretion, to decide eligibility for participation in the Employee Assistance Program. If the Administrator denies a claim for participation or benefits through this Program, the Administrator promptly and in writing shall notify the individual of such denial. The notification of denial will be made not later than within thirty (30) days of receipt of the individual's claim. This 30 day period may be extended for an additional 15 days due to circumstances beyond the control of the Plan Administrator, including cases in which a claim is incomplete. The individual will receive written notice of any such extension, including the reason for the extension and the date by which a decision by the Administrator can be expected. The Plan Administrator may secure independent information or other advice and require such other evidence as deemed necessary to decide a claim. A written notice of adverse benefit determination will be provided to the individual, and will include:
(1) the specific reason(s) for the denial of benefits,
(2) the specific Plan provision on which the denial is based,
(3) a description of any additional material or information necessary for the individual to complete a claim and an explanation of why such information is necessary, and
(4) an explanation of the right of appeal and the process to appeal the adverse benefit determination, including an explanation of the individual's right to review relevant documents and information, and his/her right to file suit under the Employee Retirement Income Security Act (ERISA) with respect to any adverse determination after appeal of a claim.
If a claim is denied in whole or in part, the individual may appeal to the Plan Administrator for review of the claim. The appeal must be made within one hundred, eighty (180) days of the Plan Administrator's initial notice of adverse benefit determination. If the appeal is not made within 180 days, the individual will lose his/her right to appeal and to file suit in court. The individual's written appeal should state the reasons that he/she believes the claim should not have been denied. It should include any relevant facts and/or documents to support the claim. The individual may ask additional questions of the Plan Administrator, make written comments, and may review (on request and at no charge) documents and other information relevant to the appeal. The Plan Administrator will review and decide the individual's appeal within a reasonable time and, within sixty (60) days after receiving the written appeal, shall render, in writing, a decision. The individual who reviews and decides the appeal will not be the same individual who originally denied the claim for benefits, or that individual's subordinate. The Plan Administrator may require additional relevant information to decide the claim. If the decision on appeal affirms the initial denial of the individual's claim for benefits under the Plan, he/she will be furnished with a notice of adverse benefit determination on review, which includes the following:
(1) the specific reason(s) for the denial,
(2) the specific Plan provision(s) on which the denial is based,
(3) a statement of the individual's right to review (on request and at no charge) relevant documents and other information,
(4) a description of any internal rule, guideline, or protocol, if applicable, used to make the benefit determination and a statement that such rule, guideline, or protocol will be provided to the claimant upon request at no charge, and
(5) a statement of the individual's right to bring suit under ERISA. Claims and appeals of adverse benefit determinations are to be addressed to Human Resources, Franklin & Marshall College, P.O. Box 3003, Lancaster, PA 17604-3003, fax (717) 291-3969.
Plan Amendment, Modification, and Termination
The Employee Assistance Program may be amended or terminated by Franklin & Marshall College at any time. Termination will also occur if the College fails to pay the required fees to the benefits provider. No consent of any employee, participant, or beneficiary is required to terminate, modify, amend, or change the Employee Assistance Program.
“COBRA” - Temporary Continuation of Coverage
The information below is intended to provide an explanation of "COBRA" continuation coverage; describe when it becomes available to an employee or retired College employee and/or eligible dependents; and describe what an employee or retiree and his/her covered dependents must do to protect the right to elect continued health coverage through COBRA, if coverage through the Plan is lost.
Employees and retirees of Franklin & Marshall College, and their dependents, who are covered under the Plan have the right to temporary continuation of their health coverage if coverage is lost due to a "Qualifying Event", as required by the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA). COBRA guarantees an opportunity to elect temporary continuation of health coverage at group rates. No evidence of insurability is required to choose continuation coverage. Coverage is the same as that for active employees or retired employees, and includes prescription drug coverage.
Qualifying Events-- An employee of Franklin & Marshall College enrolled in the Plan has the right to choose continuation coverage for him/herself, his/her covered spouse, and any covered dependent children, if the employee, spouse, or dependent children lose coverage under the Plan due to:
• a reduction in the employee's hours of work that leads to loss of eligibility for coverage through the Plan (such as during a personal leave of absence or a change from full-time to part-time status), or
• termination of the employee's employment (except for termination due to gross misconduct).
An employee who loses coverage under this Plan, due to a Qualifying Event outlined above, becomes a "Qualified Beneficiary" and is entitled to elect temporary continuation of coverage through COBRA.
The covered spouse of a College employee or retiree has the right to choose continuation coverage for him/herself and his/her covered dependent children, if the spouse or his/her covered dependent children lose coverage through the College's Plan for any of the following reasons:
• the death of the College employee or retiree,
• the reduction of the employee's hours of work,
• the termination of the employee's employment (except for termination due to gross misconduct),
• the employee or retiree becomes entitled to Medicare benefits (Medicare Part A, Part B or both), or
• the employee or retiree and his/her spouse divorce or legally separate.
A spouse who loses coverage under the Plan, due to a Qualifying Event outlined above, becomes a "Qualified Beneficiary" entitled to elect temporary continuation of coverage through COBRA.
The covered dependent child of a College employee or retiree has the right to elect COBRA continuation coverage, if coverage through the Plan is lost for any of the following reasons:
• the death of the parent (employee or retiree),
• a reduction in the parent's (employee's) work hours,
• termination of the parent's (employee's) employment (except for termination due to gross misconduct),
• the parent (employee or retiree) becomes entitled to Medicare benefits (Medicare Part A, Part B or both),
• the parents' divorce or legal separation, or
• the child ceases to be a dependent child eligible for coverage under the terms of the College's Plan (child reaching his/her age limitation, or any other “Change in Status” which effects eligibility for coverage).
A dependent child who loses coverage under the Shared Services Plan, due to a Qualifying Event outlined above, becomes a "Qualified Beneficiary" entitled to elect temporary continuation of coverage through COBRA. If a proceeding under Title 11 (bankruptcy) is filed with respect to Franklin & Marshall College, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a Qualified Beneficiary with respect to the bankruptcy. The retired employee's spouse, surviving spouse, and dependent children will also become Qualified Beneficiaries if bankruptcy results in the loss of their coverage under the Plan. In this case, the Qualified Beneficiary(ies) may elect continued coverage via COBRA.
Notification Requirements-- Continuation of coverage through COBRA will be offered upon timely and proper notice that a Qualifying Event has occurred or will occur. The covered employee/former employee or College retiree, spouse, and/or dependent child has the responsibility to inform the Plan Administrator (via Franklin & Marshall College's Human Resources department) of a Qualifying Event that results in loss of coverage under the College's Plan, such as a divorce or legal separation or loss of dependent status. Written notice to the Plan Administrator must be made within 60 calendar days of the later of: (1) the date of the Qualifying Event, (2) the date that coverage is lost due to a Qualifying Event, or (3) the date the Qualified Beneficiary is informed, through the Summary Plan Description or initial COBRA notice, of the Plan's procedures for providing notice of loss of coverage due to a Qualifying Event.
Written notice must be provided to the Plan Administrator by the employee/former employee or retiree who has lost or will lose coverage through the College's Plan, the spouse or dependent child who is losing coverage through the College's Plan, or a representative acting on behalf of the employee, retiree, spouse, or dependent child. Such notice must be sent via fax, mail, or hand-delivered to Human Resources, Franklin & Marshall College, P.O. Box 3003, Lancaster, PA 17604-3003, fax: (717) 291-3969. The written notice must include:
1. the full name of the College employee, former employee, or retired employee and his/her social security number and mailing address,
2. the name and mailing address of all dependents who have lost or will lose coverage through the Plan due to a Qualifying Event,
3. a brief description of the Qualifying Event that has resulted, or will result, in loss ofhealth coverage through the Plan (i.e., divorce, legal separation, child's loss of dependent status, etc.) and, as required, verification of the Qualifying Event,
4. the date the Qualifying Event occurred/will occur,
5. other relevant information necessary for the Plan Administrator to verify that a Qualifying Event that will lead to loss of health coverage through the College's Plan has occurred or will occur, and the date of the Qualifying Event.
When notice of a Qualifying Event is properly submitted to the Plan Administrator (via Human Resources), the Plan Administrator, or the administrator designated by the Plan Administrator, will notify the individual within 14 days of receiving the notice, if the individual is not eligible for continuation coverage through COBRA. The notice of ineligibility will include the reason(s) that continuation coverage is not available.
Employer Responsibility-- When the Qualifying Event is the termination of employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to Franklin & Marshall College, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer is responsible for notifying the Plan Administrator of the Qualifying Event.
Birth or Adoption-- If a child is born, adopted, or placed for adoption with a formerly covered employee or retired employee during the COBRA period, the employee or retiree must notify the Plan Administrator within 31 calendar days of the birth or adoption in order to elect COBRA coverage for the child.
Notice of Disability-- If the Qualifying Event that resulted in the COBRA election is termination of employment or reduction in work hours, the temporary COBRA continuation period may be extended due to the disability of any Qualified Beneficiary. In the case of disability, written notice of disability must be provided by the Qualified Beneficiary to the Plan Administrator within 60 calendar days of the latest of: (a) the date of the Social Security Administration's disability determination; (b) the date of the Qualifying Event: the employee's termination of employment or reduction of hours; (c) the date on which the Qualified Beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the employee's termination of employment or reduction of work hours; or (d) the date on which the individual is informed of the obligation to provide the disability notice, and the procedures for providing such notice, through the Plan's Summary Plan Description or the initial COBRA notice.
If disability status changes, the Plan Administrator must be notified within 30 days after the later of the date of the final determination by the Social Security Administration, or the date the Qualified Beneficiary is informed of the Plan's procedures for providing such notice.
Failure to Provide Timely and Proper Notice of a Qualifying Event-- If proper, timely written notice is not made to the Plan Administrator, all rights to continue health and prescription coverage will terminate. If proper notice of a Qualifying Event is not provided, if continuation coverage through COBRA is not elected in a timely manner, or if COBRA premiums are not paid in a timely manner by the employee/former employee, retired employee, or Qualified Beneficiary(ies), all group health and prescription coverage will terminate at the end of the calendar month in which the employment termination or other Qualifying Event occurred, in accordance with the provisions outlined in the Plan Document.
Electing COBRA Continuation Coverage-- Following a Qualifying Event, and when proper and timely written notification of a Qualifying Event that leads to loss of coverage through the Plan is provided to the Plan Administrator as required, the Qualified Beneficiary will receive a detailed notice of his/her COBRA rights, and instructions for electing COBRA coverage and paying premiums. Such notice will be sent by the College's third party COBRA administrator. To elect continuation coverage, a Qualified Beneficiary must complete an election form and furnish it within 60 calendar days according to instructions on the form. Each Qualified Beneficiary has a separate right to elect continuation coverage.
A failure to elect COBRA coverage may affect future rights under federal law, including the right to avoid having pre-existing condition exclusions applied by other group health plans.
An employee/former employee, retired employee, spouse, or covered dependent who can obtain other group health insurance coverage may request special enrollment rights within 30 days of loss of coverage through the Health Plan through the other plan.
Coverage Periods-- Continuation coverage through COBRA may be elected for a maximum period as follows:
• If the person affected by loss of coverage through Plan is the employee, and loss of coverage is due to a reduction in the employee's work hours or employment termination for reasons other than gross misconduct, the period of continuation coverage is a maximum of 18 months.
• If the person affected by loss of coverage through the Plan is an employee's or retiree's spouse, and the reason for loss of coverage is the employee's/retiree's death, divorce or legal separation, or entitlement to Medicare benefits, the period of continuation coverage is a maximum of 36 months. If an employee's hours are reduced or employment ends for reasons other than gross misconduct, the period of continuation coverage is 18 months.
• If the person affected by loss of coverage is an employee's or retiree's dependent child, and the reason for loss of coverage is the employee's/retiree's death, divorce or legal separation, entitlement to Medicare benefits, or the dependent child ceases to be a dependent eligible for coverage through the Plan, the period of continuation coverage is a maximum of 36 months. If an employee's hours are reduced or employment is terminated for reasons other than gross misconduct, the period of continuation coverage is 18 months. The period of continuation coverage described above may be shorter than expected if:
(a) the College ceases to provide any group health plan for its employees and/or retirees,
(b) the premium for continuation coverage is not paid on time by the covered individual,
(c) the individual becomes covered under another group health plan after the date COBRA is elected, unless the other coverage has certain exclusions or limitations with respect to a pre-existing condition of the individual, or
(d) the individual becomes entitled to Medicare benefits (under Part A, Part B, or both) after the date COBRA is elected. Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not receiving continuation coverage, such as due to fraud.
When the Qualifying Event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the Qualifying Event, COBRA continuation coverage for Qualified Beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his/her employment terminates, COBRA continuation coverage for the spouse and dependent children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the Qualifying Event. Otherwise, when the Qualifying Event is the end of employment or reduction of the employee's hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months.
Extension of COBRA Period Due to Disability-- If an employee loses coverage through the Plan due to termination of employment or reduction in work hours, he/she may qualify to extend the COBRA continuation period from 18 months to a maximum of 29 months if disabled. This extension applies if all of the following conditions are met:
(1) the Qualifying Event was the covered employee's termination of employment or reduction of hours;
(2) a Qualified Beneficiary (who may be the covered employee, his/her spouse, or his/her dependent child) has been issued a determination by the Social Security Administration, establishing that he/she was disabled at any time during the first 60 days of COBRA coverage;
(3) a Qualified Beneficiary notifies the Plan Administrator, via the Human Resources office, of the Social Security Administration's determination within the 18 month period that begins on the date of the Qualifying Event; and
(4) a Qualified Beneficiary notifies the Plan Administrator of the Social Security Administration's determination within 60 days after the latest of:
(a) the date of the Social Security Administration's disability determination;
(b) the date of the Qualifying Event: the employee's termination of employment or reduction of hours;
(c) the date on which the Qualified Beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the employee's termination of employment or reduction of work hours; or
(d) the date on which the individual is informed of the obligation to provide the disability notice, and the procedures for providing such notice, through the Plan's Summary Plan Description or the initial COBRA notice.
Each Qualified Beneficiary who has elected COBRA continuation coverage will be entitled to the 11 month extension if one of them qualifies.
Extension of COBRA Period Due to Second Qualifying Event-- If a spouse or dependent child experiences a second Qualifying Event while receiving health coverage through COBRA, he/she may be eligible to extend the COBRA period, up to a maximum of 36 months, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first Qualifying Event not occurred. This extension is available to the spouse and eligible dependent children if the College employee/former employee, or retired employee dies, becomes entitled to Medicare benefits (Part A, Part B, or both), gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first Qualifying Event not occurred. Proper written notice of a second Qualifying Event must be made to the Plan Administrator, as outlined above under "Notification Requirements", within 60 calendar days of the second Qualifying Event.
COBRA Premiums-- COBRA participants / beneficiaries pay 100% of the group rate premium for continuation coverage (100% of the actuarially-derived premiumequivalent), plus a 2% administrative fee. Current monthly premiums are as follows: $1.52 per person
Making COBRA Payments-- When an employee/former employee, spouse, and/or dependent child elects COBRA coverage, he/she, or a third party representing the COBRA recipient, must make the first payment for such coverage not later than 45 calendar days after the date of his/her election of continued coverage. If the first payment is not made in full in a timely manner, rights to continued coverage will be forfeited.
Subsequent payments, after the first payment, are subject to a 30 day grace period; continuation coverage will be provided for each coverage period as long as payment is made before the end of the grace period. However, if payment is made later than the first day of the coverage period, but before the end of the grace period, COBRA coverage will be suspended as of the first day of the coverage period and then reinstated, retroactively, when proper payment is received. If a COBRA participant fails to make a periodic payment before the end of the grace period, he/she will lose all rights to COBRA continuation coverage.
Under the Health Insurance Portability & Accountability Act, in certain circumstances, such as when COBRA coverage terminates, an individual may have the right to buy individual health coverage with no pre-existing condition exclusion, and without providing evidence of good health.
Questions about COBRA may be directed to the Franklin & Marshall College Human Resources office, Ceridian Benefits Services, the College's 3rd party COBRA administrator, (800) 877-7994, or the U.S. Department of Labor's Employee Benefits Security Administration, www.dol.gov/ebsa.
Health Insurance Portability and Accountability Act of 1996
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which coverage may be excluded for medical conditions present before a participant enrolls in a group health insurance plan ("pre-existing conditions"). In addition, HIPAA prevents discrimination against individuals based on their health status, and allows for special enrollment periods under certain circumstances. HIPAA also regulates the use and disclosure of "Protected Health Information".
Pre-existing Condition Exclusions-- Under the law, a pre-existing condition exclusion generally may not be imposed for more than 12 months (18 months for a late enrollee). The 12 month exclusion period is reduced by an individual's prior health coverage. If, at the time an employee enrolls in a new employer's health plan, he/she already has had 12 months of continuous health coverage, without a break in coverage of 63 days or more, the employee will not have to start over with a new 12 month exclusion for any preexisting medical conditions. If an individual was previously covered, he/she is entitled to a certificate of prior coverage from the third party administrator. A "Certificate of Creditable Coverage" must be provided to the individual by the plan when coverage is lost. Under HIPAA, pre-existing condition exclusions may not be applied to pregnancy. In addition, pre-existing condition exclusions may not be applied to a newborn, an adopted child, or a child placed for adoption who is under age 18 as long as the child becomes covered under the health plan within 31 calendar days of birth, adoption, or placement for adoption, and provided the child does not incur a subsequent 63 day or more break in coverage. The Plan includes no pre-existing condition exclusions.
Health Status Discrimination-- HIPAA prohibits group health plans from establishing eligibility rules based on health status-related factors (such as medical condition, claims experience, medical history, genetic information, or disability). Plans may not require individuals to pay a greater premium based on a health status-related factor. However, plans may establish limits or restrictions on benefits or coverage for similarly situated individuals.
Special Enrollment Provisions-- HIPAA provides for special enrollment periods under certain circumstances. If an employee or retiree declines coverage under the Shared Services Health Plan for him/herself and/or eligible dependents because of other coverage, the individual may be able to enroll him/herself and/or eligible dependents in the Plan, providing the appropriate enrollment form is completed and submitted within 31 calendar days after other coverage, including "COBRA", terminates due to loss of eligibility for such coverage. Under HIPAA, special enrollment rights are also granted when an employer's contributions toward an individual's other health insurance coverage ceases. In addition, if an employee or retiree acquires a new eligible dependent(s) through marriage, birth, adoption, or placement for adoption, such dependent may be enrolled in the Shared Services Health Plan within 31 days of the birth, adoption, or placement for adoption, or in the case of marriage, within 31 days of the 1st of the calendar month after the date of marriage. Under these circumstances, it is not necessary to wait until the annual Open Enrollment period to enroll in the Plan. The maximum pre-existing condition exclusion period for special enrollees is 12 months, reduced by the special enrollee's creditable coverage. No pre-existing condition exclusions may apply to a child if enrolled within 31 days of birth, adoption, or placement for adoption.
HIPAA Notice of Privacy Practices
THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices (the “Notice”) describes the legal obligations of the Franklin & Marshall College group health plan (the “Plan”) and your legal rights regarding your protected health information held by the Plan under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Among other things, this Notice describes how your protected health information may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law.
This Notice applies to the following employee benefit plans (the “Plan”) that are sponsored by Franklin & Marshall College (the “Employer”): the Franklin & Marshall Shared Services Health Plan; the Dental Plan; the Employee Assistance Program; the Flexible Spending Accounts Plan; the Health Reimbursement Arrangement; and the Emeriti Retirement Health Plan.
We are required to provide this Notice of Privacy Practices to you pursuant to HIPAA.
The HIPAA Privacy Rule protects only certain medical information known as “protected health information” or “PHI”. Generally, protected health information is individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health care clearinghouse, a health plan, or your employer on behalf of a group health plan that relates to:
(1) your past, present or future physical or mental health or condition;
(2) the provision of health care to you; or
(3) the past, present or future payment for the provision of health care to you.
If you have any questions about this Notice or about our privacy practices, please contact the designated Privacy Official:
Director, Human Resources, Privacy Official
Franklin & Marshall College
PO Box 3003
Lancaster, PA 17604-3003
This Notice is effective September 23, 2013
We are required by law to:
• maintain the privacy of your protected health information;
• provide you with certain rights with respect to your protected health information;
• provide you with a copy of this Notice of our legal duties and privacy practices with respect to your protected health information; and
• follow the terms of the Notice that is currently in effect.
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain, as allowed or required by law. If we make any material change to this Notice, we will provide you with a copy of our revised Notice of Privacy Practices via any reasonable method or by mailing a revised notice to your last-known address on file.
How We May Use and Disclose Your Protected Health Information
Under the law, we may use or disclose your protected health information under certain circumstances without your permission. The following categories describe the different ways that we may use and disclose your protected health information. For each category of uses or disclosures we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Payment. We may use or disclose your protected health information to determine your eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, we may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational, or medically necessary, or to determine whether the Plan will cover the treatment. We may also share your protected health information with a utilization review or precertification service provider. Likewise, we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments.
For Health Care Operations. We may use and disclose your protected health information for other Plan operations. These uses and disclosures are necessary to run the Plan. For example, we may use medical information in connection with conducting quality assessment and improvement activities; underwriting, premium rating, and other activities relating to Plan coverage; submitting claims for stop-loss (or excess-loss) coverage; conducting or arranging for medical review, legal services, audit services, and fraud & abuse detection programs; business planning and development such as cost management; and business management and general Plan administrative activities.
To Business Associates. We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services. In order to perform these functions or to provide these services, Business Associates will receive, create, maintain, use and/or disclose your protected health information, but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information. For example, we may disclose your protected health information to a Business Associate to administer claims or to provide support services, such as utilization management, pharmacy benefit management, claims management, nurse navigation, or subrogation, but only after the Business Associate enters into a Business Associate contract with us.
As Required by Law. We will disclose your protected health information when required to do so by federal, state or local law. For example, we may disclose your protected health information when required by national security laws or public health disclosure laws.
To Avert a Serious Threat to Health or Safety. We may use and disclose your protected health information when necessary to prevent a serious threat to your health and safety, or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. For example, we may disclose your protected health information in a proceeding regarding the licensure of a physician.
To Plan Sponsors. For the purpose of administering the plan, we may disclose to certain employees of the Employer protected health information. However, those employees will only use or disclose that information as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized further disclosures. Your protected health information cannot be used for employment purposes without your specific authorization.
In addition to the above, the following categories describe other possible ways that we may use and disclose your protected health information. For each category of uses or disclosures, we will explain what we mean and present some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
Military and Veterans. If you are a member of the armed forces, we may release your protected health information as required by military command authorities. We may also release protected health information about foreign military personnel to the appropriate foreign military authority.
Workers' Compensation. We may release your protected health information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose your protected health information for public health actions. These actions generally include the following:
• to prevent or control disease, injury, or disability;
• to report births and deaths;
• to report child abuse or neglect;
• to report reactions to medications or problems with products;
• to notify people of recalls of products they may be using;
• to notify a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition;
• to notify the appropriate government authority if we believe that a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree, or when required or authorized by law.
Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities authorized by law. These by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your protected health information in response to a court or administrative order. We may also disclose your protected health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may disclose your protected health information if asked to do so by a law enforcement official—
• in response to a court order, subpoena, warrant, summons or similar process;
• to identify or locate a suspect, fugitive, material witness, or missing person;
• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the victim's agreement;
• about a death that we believe may be the result of criminal conduct; and
• about criminal conduct.
Coroners, Medical Examiners and Funeral Directors. We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors, as necessary to carry out their duties.
National Security and Intelligence Activities. We may release your protected health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Inmates. If you are an inmate of a correctional institution or are in the custody of a law enforcement official, we may disclose your protected health information to the correctional institution or law enforcement official if necessary
(1) for the institution to provide you with health care;
(2) to protect your health and safety or the health and safety of others; or
(3) for the safety and security of the correctional institution.
Research. We may disclose your protected health information to researchers when:
The following is a description of disclosures of your protected health information we are required to make.
Government Audits. We are required to disclose your protected health information to the Secretary of the United States Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA privacy rule.
Disclosures to You. When you request, we are required to disclose to you the portion of your protected health information that contains medical records, billing records, and any other records used to make decisions regarding your health care benefits. We are also required, when requested, to provide you with an accounting of most disclosures of your protected health information if the disclosure was for reasons other than for payment, treatment, or health care operations, and if the protected health information was not disclosed pursuant to your individual authorization.
Personal Representatives. We will disclose your protected health information to individuals authorized by you, or to an individual designated as your personal representative, attorney-in-fact, etc., so long as you provide us with a written notice/authorization and any supporting documents (i.e., power of attorney). Note: Under the HIPAA privacy rule, we do not have to disclose information to a personal representative if we have a reasonable belief that:
Spouses and Other Family Members. With only limited exceptions, we will send all mail to the employee. This includes mail relating to the employee's spouse and other family members who are covered under the Plan, and includes mail with information on the use of Plan benefits by the employee's spouse and other family members and information on the denial of any Plan benefits to the employee's spouse and other family members. If a person covered under the Plan has requested Restrictions or Confidential Communications (see below under “Your Rights”), and if we have agreed to the request, we will send mail as provided by the request for Restrictions or Confidential Communications.
Authorizations. Other uses or disclosures of your protected health information not described above will only be made with your written authorization. Examples include, but are not limited to, psychotherapy notes, uses and disclosures for marketing purposes and any sale of PHI. You may revoke written authorization at any time, so long as the revocation is in writing. Once we receive your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.
Underwriting. If the group health plan uses PHI for underwriting purposes, the plan will not use or disclose genetic information for underwriting purposes.
You have the following rights with respect to your protected health information:
Right to Inspect and Copy. You have the right to inspect and copy certain protected health information that may be used to make decisions about your health care benefits. To inspect and copy your protected health information, you must submit your request in writing to the Privacy Official. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your medical information, you may request that the denial be reviewed by submitting a written request.
Right to Amend. If you feel that the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan.
To request an amendment, your request must be made in writing and submitted to the Privacy Official. In addition, you must provide a reason that supports your request.
We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
• is not part of the medical information kept by or for the Plan;
• was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• is not part of the information that you would be permitted to inspect and copy; or
• is already accurate and complete.
If we deny your request, you have the right to file a statement of disagreement with us and any future disclosures of the disputed information will include your statement.
Right to an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your protected health information. The accounting will not include (1) disclosures for purposes of treatment, payment, or health care operations; (2) disclosures made to you; (3) disclosures made pursuant to your authorization; (4) disclosures made to friends or family in your presence or because of an emergency; (5) disclosures to business associates; (6) disclosures for national security purposes; and (7) disclosures incidental to otherwise permissible disclosures.
To request this list or accounting of disclosures, you must submit your request in writing to the Privacy Official. Your request must state a time period of not longer than the past six years. Your request should indicate in what form you want the list (for example, paper or electronic). The first list you request within a 12-month period will be provided free of charge. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions. You have the right to request a restriction or limitation on your protected health information that we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on your protected health information that we disclose to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery that you had.
Except as provided in the next paragraph, we are not required to agree to your request. However, if we do agree to the request, we will honor the restriction until you revoke it or we notify you.
Effective February 17, 2010 (or such other date specified as the effective date under applicable law), we will comply with any restriction request if (1) except as otherwise required by law, the disclosure is to the health plan for purposes of carrying out payment or health care operations (and is not for purposes of carrying out treatment); and (2) the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out-of-pocket in full.
To request restrictions, you must make your request in writing to the Privacy Official. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply— for example, disclosures to your spouse.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.
To request confidential communications, you must make your request in writing to the Privacy Official. We will not ask you the reason for your request. Your request must specify how or where you wish to be contacted. We will accommodate all reasonable requests if you clearly provide information that the disclosure of all or part of your protected information could endanger you.
Right to Be Notified of a Breach. You have the right to be notified in the event that we (or a Business Associate) discover a breach of unsecured protected health information.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice contact the Privacy Official identified on the first page of this Notice.
If you believe that your privacy rights have been violated, you may file a complaint with the Plan or with the Office for Civil Rights of the United States Department of Health and Human Services. To file a complaint with the Plan, contact the Privacy Official. All complaints must be submitted in writing.
You will not be penalized, or in any other way retaliated against, for filing a complaint with the Office for Civil Rights or with us
Security of Protected Health Information-- With respect to Electronic Protected Health Information (ePHI), the Plan Sponsor will:
• Implement administrative, physical, and technical standards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic PHI;
• Ensure that the firewall required by the HIPAA privacy rule is supported by reasonable and appropriate security measures;
• Ensure that any agent or subcontractor to whom the Plan Sponsor provides electronic PHI agrees to implement reasonable and appropriate security measures; and
• Report to the Plan any security incident of which the Plan Sponsor becomes aware.
Electronic PHI is health information about a Plan participant that is in an electronic format. Health information includes information about the individual's past, present, or future physical or mental condition, the provision of health care to the individual, or the past, present, or future payment for the provision of health care to the individual.
Complaints-- If you feel that your privacy rights as described in this Notice have been violated, you may complain to the Plans by contacting the individual named below. You may also file a complaint with the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Ave. SW., Washington, DC 20201.
The Plans will not retaliate or discriminate against you for filing a complaint.
Contact Information-- If you have any questions about this Notice or would like to file a complaint, you may contact:
The Director, Human Resources
Franklin & Marshall College
P.O. Box 3003
Lancaster, PA 17604-3003
Coverage During Family & Medical Leave
If a covered College employee takes a qualifying leave under the Family & Medical Leave Act of 1993, as amended (FMLA), then to the extent required by the FMLA, the College will continue to maintain the employee's coverage through the Employee Assistance Program on the same terms and conditions as if the employee were still an active employee.
Continuation of Coverage under USERRA
The Uniformed Services Employment and Reemployment Rights Act of 1994 ("USERRA") requires employers to provide coverage during qualified service of an employee in the Uniformed Services. This continued coverage, although similar to COBRA, may in certain circumstances provide rights in addition to those under COBRA. If an employee is on a qualified leave of absence under USERRA, when making an election to continue coverage under COBRA, the employee will also be making an election under USERRA. Where COBRA and USERRA provide different benefit protections, the law that provides greater protection will apply. For example, under USERRA if an employee is on a qualified leave of absence that lasts less than 31 days, the employee cannot be required to pay an insurance premium greater than what he/she would have paid if the employee had remained at work during this period. During a Service leave, a full-time College employee will be eligible for coverage through the Plan for him/herself and covered dependents, at active employee rates, for up to 30 calendar days. In the case of Service leave exceeding 30 calendar days, USERRA requires the College to extend coverage to the employee and his/her covered dependents, at 102% of the full premium, until the lesser of 24 months from the date the employee's civilian employment ended, or until the end of the period allowed for the individual to apply for reemployment. COBRA rights also apply to the employee and each of his/her covered dependents.
Statement of ERISA Rights
Participants in the Plan are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974, as amended (ERISA). ERISA provides that all Plan participants are entitled to the following rights:
Receive information about the Plan and benefits-- Examine, without charge, at the Plan Administrator's office and at other specified locations, all documents governing the Plan (including, if applicable, insurance contracts and collective bargaining agreements), and a copy of the latest annual report (Form 5500 Series) filed by the Plan, if the Plan is required to do so, with the U.S. Department of Labor and available at the Public
Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, (including, if applicable, insurance contracts and collective bargaining agreements), and copies of the latest annual report (Form 5500 Series), if the Plan is required to file such form, 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, if the Plan is required to
Prepare such a report-- The Plan Administrator is required by law to furnish each participant with a copy of any summary annual report.
Continue Plan coverage-- Continue health coverage for self, and dependent spouse or dependent children if applicable, if there is a loss of coverage under the Plan as a result of a Qualifying Event. A participant and his/her dependents will be required to pay for such coverage. This Summary Plan Description includes rules governing COBRA continuation coverage rights.
Reduction or elimination of exclusionary periods of coverage for pre-existing conditions under the Plan, if you have Creditable Coverage for another plan-- You should be provided a Certificate of Creditable Coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under a health insurance plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of Creditable Coverage, an individual may be subject to a preexisting condition exclusion for 12 months (up to 18 months for late enrollees) after enrolling in a health insurance plan.
Prudent action by Plan Fiduciaries-- In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of an employee benefit plan. The people who operate this 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 or any other person, may terminate your employment or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
Enforce your rights-- If a 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.
Under ERISA, there are steps participants can take to enforce the above rights. For instance, if you request a copy of the Plan documents or the latest annual report (if applicable) 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 Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, 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.
Assistance with Questions
If you have any questions about the Program, you should contact the Plan Administrator, via Franklin & Marshall College's Human Resources department. 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, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
In no case will a Program participant, or anyone acting on a participant's behalf, be entitled to challenge a decision of the Plan Administrator in court or in any other administrative proceeding unless and until the claim and appeal procedures described in this Summary Plan Description have been complied with and exhausted.