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Health and Prescription Drug Coverage, and HRA

This Summary Plan Description describes the health, prescription drug, and vision care coverage available to eligible employees and retired employees of Franklin & Marshall College (“the College”) through the Shared Services Health Plan (the “Health Plan” or "Plan"), as in effect on January 1, 2014. This Summary Plan Description (“SPD”) is required by The Employee Retirement Income Security Act (ERISA) of 1974, as amended. The purpose of this SPD is to acquaint employees, including retired College employees, with the provisions of the Plan, 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 SPD as accurate as possible. However, in the event of a discrepancy between this SPD 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.

Shared Services Health Plan participants receive a packet of information from the Plan’s third party administrator and the vision benefits administrator upon enrollment in the Plan, including a Benefits Booklet (which includes a Summary of Benefits) and a Summary of Vision Care Benefits. The Benefits Booklet and Summary of Vision Care Benefits contain important details about the Health Plan, including coverage levels, covered and non-covered services, exclusions, and pre-certification requirements. Some medical services and procedures, as well as prescription medicines and vision services, may not be covered through the Shared Services Health Plan. Plan participants are strongly encouraged to carefully read the Benefits Booklet and Summary of Vision Care Benefits.  Copies of these documents are available in the Human Resources public eDisk folder, and from the Human Resources office.

Please note:  The information in this Summary Plan Description does not apply to retired employees of Franklin & Marshall College who retired on or after January 1, 2013, with the exception of retired College faculty members who entered into a formal Phased Retirement or Pre-retirement Leave of Absence Agreement no later than by December 31, 2012.  

Eligible faculty members who signed a Phased Retirement or Pre-retirement Leave of Absence Agreement by December 31, 2012, may enroll in this Shared Services Health Plan upon retirement.  Other eligible full-time employees of Franklin & Marshall who retire on or after January 1, 2013, may enroll in medical and prescription drug plans offered through the Emeriti Retirement Health Plan during retirement.  Such employees who retire(d) on or after January 1, 2013, should see the Emeriti Retirement Health Plan Summary, available from  http://www.fandm.edu/humanresources/benefits, for information about their medical and prescription drug coverage options during retirement.

Facts About the Plan

Plan Name: Shared Services Health Plan

Plan Number: 501 - Plan 501 also includes the Franklin & Marshall College Group Dental Plan, the Franklin & Marshall College Group Life Insurance Plan, the Franklin & Marshall College Health Reimbursement Arrangement, and the Franklin & Marshall College Flexible Spending Accounts Plan which are each described in a separate Summary Plan Description.

Name, Address, and Telephone Number of Employer: Franklin & Marshall College, Lancaster, PA 17604-3003, (717) 291-3995. Employer shall also include the Lancaster City Alliance.

Plan Sponsor’s Employer Identification Number: 25-1882792

Original Plan Effective Date: November 1, 2008; Amended and restated as of January 1, 2011

Plan Year: July 1 through June 30

Benefits Year: January 1 through December 31

Type of Plan: Welfare Plan providing medical, prescription drug, and vision benefits

Plan Administrator: Franklin & Marshall College, P.O. Box 3003, Lancaster, PA, 17604

Named Fiduciary for benefits provided to Franklin & Marshall College Plan Participants: Franklin & Marshall College, Lancaster, PA 17604-3003

Plan Benefits Determined By:  The third party administrator for the medical and prescription drug benefits, Highmark Blue Shield (“Highmark”), determines whether services and supplies are eligible for coverage through the Group Health Plan, and reviews and processes eligible claims. Vision benefit claims are processed by National Vision Administrators, LLC ("NVA"), 1200 Route 46 West, Clifton, NJ, 07013.

Agent for Service of Legal Process: Shared Services Consortium, LLC, 6 Kacey Court, Mechanicsburg, PA  17055 (717) 796-2200.

Funding: Costs associated with providing group health, prescription drug, and vision coverage through the Shared Services Health Plan are paid by Franklin & Marshall College, through general employer assets; by enrolled College employees, through payroll deductions that can be made, at the employee's election, either pre-tax or after taxes have been withheld from salary; enrolled retired employees; and COBRA participants.

 

Plan Benefits:

Medical Coverage

Medical coverage is provided for eligible employees, benefits-eligible retired employees, and their eligible dependents enrolled in the Group Health Plan. Franklin & Marshall College currently offers the following “Preferred Provider Organization” (PPO) health plan options, administered by Highmark Blue Shield:

  1. the PPO Health Plan $1,000 with Health Reimbursement Account, a High Deductible Health Plan with a College-funded Health Reimbursement Account for employees and their eligible dependents ("PPO Health Plan $1,000 + HRA"),
  1. the PPO Health Plan $300 for employees, retired College employees, and eligible dependents ("PPO Health Plan $300"),

Medical and prescription drug benefits as described in the Benefits Booklet from the third party administrator are provided under the Group Health Plan. Coverage is provided for eligible services and supplies that are Medically Necessary and Appropriate as described in the Benefits Booklet.

A copy of the Benefits Booklet is provided to each participating College employee and retired employee upon enrollment. Additional copies are available to any participant or beneficiary, at no charge, from Franklin & Marshall College, Human Resources, P.O. Box 3003, Lancaster, PA 17604-3003, (717) 291-3995, and from Highmark Blue Shield, (800) 345-3806 or on their website at www.highmarkblueshield.com.  Copies of the Benefits Booklet are also available through eDisk, in the "Groups", "Human Resources" "Public" folder. A listing of Participating Providers can be found by calling Highmark Blue Shield at (800) 345-3806, or via their website at www.highmarkblueshield.com.

The Benefits Booklet from the third party administrator includes important details about medical and prescription drug benefits, including coverage levels, covered and non-covered services, exclusions, pre-certification requirements, and claims procedures. Some medical services and procedures may not be covered through the Health Plan, even if Medically Necessary and Appropriate (as defined in the Benefits Booklet). Plan participants are strongly encouraged to read the Benefits Booklet.

The PPO Health Plan $1,000 + HRA includes an employer-funded Health Reimbursement Account.  This Account is described in the Summary Plan Description for the Health Reimbursement Account Plan.  The Summary Plan Description is available from the Human Resources office and at www.fandm.edu/humanresources/benefits.

Network Benefits

Each time a Plan participant seeks medical care, the participant decides whether to receive treatment from a “Network” health care provider and receive the highest level of coverage, or seek treatment from an “Out-of-Network” health care provider and receive a reduced level of coverage. A Network provider is a health care provider (including hospital, primary care physician, specialty care physician, and other licensed and accredited health care practitioner) who is contracted with the third party administrator (Highmark Blue Shield) to provide services to Plan participants, and participates in the third party administrator's provider network.

If Medically Necessary and Appropriate treatment is provided by a Network health care provider in accordance with the third party administrator's utilization management policies and procedures, most eligible services are covered at a 100% level, after applicable co-payments, coinsurance, and applicable deductibles have been paid by the participant.

Enrolled employees, College retirees, and covered dependents living outside the third party administrator's local service area may receive health care services from providers who participate in their own local Blue Cross Blue Shield PPO network. Medically Necessary and Appropriate covered services will be covered at the Network level of benefits.  If a provider is not part of the local Blue Cross Blue Shield PPO network, services will be covered at the lower Out-of-Network level of benefits. 

Out-of-Network Benefits

Out-of-Network health care providers are those who are not contracted with the third party administrator (Highmark Blue Shield) to provide services to Plan participants. If a Plan participant receives Medically Necessary and Appropriate treatment from an Out-of-Network health care provider, a lower level of coverage applies.  “Coinsurance”, or the amount paid by the Health Plan, equals 70% of “Provider’s Reasonable Charges” if a participant is enrolled in the PPO Health Plan $1,000 + HRA or the PPO Health Plan $300.  “Provider’s Reasonable Charges” are those determined by the third party  administrator to be reasonable fees.  The “Provider’s Reasonable Charge” is used to calculate the payment to a provider and the Plan participant’s liability.  The participant is responsible for paying coinsurance charges (30%) plus all charges in excess of the "Provider’s Reasonable Charges”, in addition to applicable co-payments and deductibles. When receiving treatment from an Out-of-Network, non-participating health care provider, a participant may incur substantial costs that will not be reimbursed through the Health Plan.

BlueCard and BlueCard Worldwide – Out-of-Area and Worldwide Care

Most Medically Necessary and Appropriate services that are received from health care providers across the country and worldwide who participate in the “BlueCard” or “BlueCard Worldwide” network (their local Blue Shield PPO network) are covered at 100%, after the participant pays applicable co-payments, coinsurance, and deductibles. 

If a Plan participant receives covered services from a provider who is not part of a  BlueCard network, services will be covered at a lower level - 70% if enrolled in the PPO Health Plan $1,000 + HRA or PPO Health Plan $300.  The amount that a Plan participant will be reimbursed for covered services is a percentage (70%) of the lesser of: (a) the billed charges or (b) the   negotiated price that the on-site Blue Cross or Blue Shield Plan (“Host Blue”) passes on to Highmark Blue Shield.  Please see the Benefits Booklet for more information on how these charges are calculated. When receiving treatment from a health care provider who does not participate in the BlueCard network, a Plan participant may incur substantial costs that will not be reimbursed through the Health Plan.

When receiving health care services abroad, the Plan participant may be required to pay the provider and then complete and submit an international claim form. The claim form may be obtained by calling the third party administrator (Highmark Blue Shield).

As noted below, treatment which is considered emergency medical care, as determined by the third party administrator, is covered at the Network level, whether provided by an In-Network or Out-of-Network health care provider.  For participants enrolled in the PPO Health Plan $1,000 + HRA or the PPO Health Plan $300, all emergency room visits are subject to a $50 co-payment, which must be paid by the participant.  This emergency room co-payment is waived if the participant is admitted as an inpatient to a hospital and the applicable inpatient co-payment applies.

Annual Benefit Maximum—Not applicable; there is no annual maximum benefit associated with the Plan.  

Claim Forms-- Participants who receive treatment from a Network (participating) health care provider are not required to submit claim forms to the third party administrator. Plan participants may be required to submit a claim form to the third party administrator if they receive services from an Out-of-Network (non-participating) health care provider.

Emergency Care-- Treatment which is considered emergency medical care, as determined by the third party administrator, is provided within and outside the provider network, as described in the Benefits Booklet. Coverage at the Network level of benefits is provided for emergency care received from either a Network (participating) or Out-of-Network (non-participating) provider. For participants enrolled in the PPO Health Plan $1,000 + HRA or the PPO Health Plan $300, all emergency room visits are subject to a $50 co-payment, which must be paid by the participant. 

Pre-certification Requirements-- The Group Health Plan provides coverage for covered services that are Medically Necessary and Appropriate. Pre-certification, through the Plan’s third party administrator, is required for all inpatient admissions and certain outpatient procedures, including physical therapy, to determine medical necessity and appropriateness.  Highmark Healthcare Management Services must pre-certify all inpatient admissions.  Planned admissions must be pre-certified prior to the admission; emergency and maternity admissions must be certified within 48 hours of the admission.

Some facility providers will obtain pre-certification of the inpatient admission on the Plan participant’s behalf.  Plan participants should verify through Highmark that the certification has occurred.  If the facility does not pre-certify the admission on the participant’s behalf, the Plan participant is to contact Highmark Healthcare Management Services directly.  Necessary phone numbers are listed on the Highmark health plan ID card. The Group Health Plan will not provide coverage for treatment that is not determined to be Medically Necessary and Appropriate.

Pre-existing Condition Exclusions-- There are no pre-existing condition exclusions contained in the Health Plan.

Referrals—A referral from a Plan participant's Primary Care Physician is not required before visiting another provider or specialist.  Pre-certification is required for some services in order for coverage to be provided, as explained above and in the Benefits Booklet.

 

Prescription Drug Coverage

Prescription drug coverage is provided for employees, retired employees, and their eligible dependents enrolled in the Group Health Plan. Coverage is provided for included prescription drugs and supplies which are prescribed by a licensed physician, dentist, or health care provider for use by the Plan participant. Prescription medicines are drugs approved by the FDA for a specific use that may be dispensed only through a prescription order or refill.

To receive coverage, Plan participants must purchase prescription medicines from a Highmark Network - participating - pharmacy and must show their Highmark Blue Shield identification card at the time of purchase.  Many prescription medicines used on a regular basis may be purchased through the Medco mail order program.  Coverage is not provided through the Health Plan if prescription medicines are purchased from an Out-of-Network or non-participating provider.

Prescription drug coverage is subject to the exclusions and limitations outlined in the Benefits Booklet.  The Benefits Booklet contains important information about prescription drug coverage, including covered and non-covered medicines and exclusions. Some prescription medicines are not covered through the Group Health Plan, including but not limited to experimental/investigative drugs; most vitamin and mineral supplements; most over-the-counter products, medicines, and supplies; hair growth stimulants; blood products; and drugs prescribed for cosmetic purposes. Coverage for some prescription medicines is provided only up to specified quantities and/or dosages. Plan participants are strongly encouraged to read the Prescription Drug provisions of the Benefits Booklet or may contact the third party administrator (Highmark).

Generic Substitution Requirement-- The Health Plan provides coverage for generic as well as brand name drugs.  However, if a Plan participant purchases a brand name drug when a generic alternative exists, the participant will be required to pay the required brand name co-payment, plus the full difference between the generic drug cost and the brand name drug cost.

Vision Care Benefits

Coverage for certain routine vision care services and eyewear is provided for employees, retired employees, and their eligible dependents enrolled in the Group Health Plan.  Coverage is provided as stated in the Schedule of Vision Care Benefits, available from the Human Resources office and in the Human Resources public eDisk folder.  Coverage and annual benefit limits apply and not all services are covered.

Coverage Limits

Coverage limits apply to certain services and supplies as listed in the Benefits Booklet and the Schedule of Vision Care Benefits, even if such services are Medically Necessary and Appropriate.  Services with coverage or benefit limits include spinal manipulations, physical medicine, speech therapy, occupational therapy, prosthetics, home health services, infertility treatment, private duty nursing, treatment in a skilled nursing facility, and vision services and supplies. Coverage limits also apply to certain prescription medicines.

The above represents only a summary of services and supplies for which calendar year coverage limits or benefit limits apply. The Benefits Booklet and Schedule of Vision Care Benefits contain a listing of services, supplies, and medicines for which limited coverage is provided. A copy of these documents may be obtained by contacting the Plan Administrator (via Human Resources), Highmark Blue Shield, or National Vision Administrators (NVA).

 

Excluded Services

Coverage for some medical services, treatments, and supplies is not provided through the Health Plan, even if Medically Necessary and Appropriate.  Additionally, services that are not considered Medically Necessary and Appropriate, as determined by the third party administrator, are not covered.  The Health Plan does not provide coverage for any dental or other services except as provided in the Benefits Booklet.  The Benefits Booklet includes a full list of Plan benefits, limits, and exclusions, and should be carefully read by each participant.

Eligibility for Coverage

The following classes of employees, and their eligible dependents, may enroll in the College’s Shared Services Group Health Plan:

Class A:

  • “full-time” faculty and professional staff employees: Franklin & Marshall College employees who are appointed to full-time positions and authorized and 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; the current, actively employed Spectrometer Technician; 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 appointed to full-time positions and authorized and 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 or Pre-retirement Leave of Absence Agreement
  • full-time faculty who have been granted a leave of absence to further their scholarship and/or teaching and who receive a stipend from a competitive grant or fellowship that does not provide health insurance coverage, upon approval of the Provost and Dean of the Faculty and per provisions of the College’s Faculty Handbook (eligibility for coverage may continue for the time period covered by the grant or fellowship, not to exceed 12 months)
  • full-time faculty on an approved paid sabbatical or paid Junior Faculty Leave, not to exceed 12 months
  • 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, not to exceed 12 months

Please note:  No member of the faculty or staff appointed to a position classified as “part-time” is permitted to work more than 29 hours per week for wages without advance written authorization from his/her Senior Officer and the Director, Human Resources.

Coverage is provided for the eligible employee; the employee plus one dependent; or the employee plus two or more dependents.

Class B:

  • Medicare-enrolled retired employees who retired prior to January 1, 2013: full-time College employees who, on the date active employment is terminated, have completed at least ten (10) consecutive full years of full-time employment with Franklin & Marshall College in a benefits-eligible class after the age of 50 (are at least age 60 with at least 10 consecutive years of full-time employment with Franklin & Marshall College after the age of 50), and who are eligible and enrolled through the federal Medicare program

Class C:

  • full-time faculty members who meet all criteria for participation in the Phased Retirement Program or Pre-retirement Leave of Absence Program; who signed a Phased Retirement Agreement or Pre-retirement Leave of Absence Agreement on or before December 31, 2012; and who terminated their employment under an approved Phased Retirement Agreement  or Pre-retirement Leave of Absence Agreement which provides continued coverage through this Shared Services Group Health Plan
  • full-time professional staff members who terminated their employment prior to January 1, 2013, under an approved Voluntary Early Retirement Program Agreement which provides continued coverage through this Shared Services Group Health Plan

Class D:

  • non-Medicare-eligible retired employees who retired prior to January 1, 2013: full-time College employees who, on the date active employment is terminated, have completed at least ten (10) consecutive full years of full-time employment with Franklin & Marshall College in a benefits-eligible class after the age of 50 (are at least age 60 with at least 10 consecutive years of full-time employment with Franklin & Marshall College after the age of 50); are not eligible, or not yet eligible, for coverage through the federal Medicare program; and did not terminate employment via an approved College early retirement program which provided continued Health Plan coverage at reduced rates

For classes B, C, and D, coverage is provided for the College retiree; the retiree plus one dependent; or the retiree plus two or more dependents.

Retired employees are not eligible for coverage through the PPO Health Plan $1,000 + HRA, except on a temporary basis following employment termination as permitted through "COBRA".

Note: Coverage through this Shared Services Group Health Plan is available to eligible employees who retired prior to January 1, 2013, and to eligible members of the faculty who signed a Phased Retirement Agreement or Pre-retirement Leave of Absence Agreement on or before December 31, 2012.  Employees retiring on or after January 1, 2013 (with the exception of faculty who signed a Phased Retirement or Pre-retirement Leave of Absence Agreement by December 31, 2012) should see the Emeriti Retirement Health Plan Summary Plan Description for information about their coverage.

A retired College employee who is eligible for coverage through the federal Medicare program, and his/her covered dependent, if applicable, who is eligible for coverage through Medicare, must enroll in Medicare Parts A and B on the earliest possible date following employment termination in order to retain coverage through the College’s Group Health Plan.  Currently, there is no requirement that retired employees enroll in a Medicare Part D prescription plan.

Independent contractors; contracted employees; adjunct faculty; employees appointed to positions classified as “part-time”; individuals who volunteer their services without compensation; students; student employees; and those not in a covered class are not eligible for coverage through the Group Health Plan.

Eligible Dependents

For purposes of the Group Health Plan, eligible dependents who can be enrolled through the Plan are:

1.     a covered employee's or retiree's legally-recognized spouse, including the legally- recognized same-sex spouse, or same-sex Domestic Partner as defined by the College's policies, and

2.     dependent children through age 25 (under age 26).

A Domestic Partner is defined as the unmarried partner of a College employee or retired employee who is:

1) of the same sex as the employee or retiree, and

2) sharing a long-term, committed relationship of indefinite duration with the employee or retiree, with all of the following characteristics:

(a) the partners have an exclusive mutual commitment similar to that of marriage, the partners live together, and the partners intend to maintain their commitment indefinitely,

(b) neither partner is legally married to anyone else or has another domestic partner,

(c) the partners are not related by blood closer than would bar marriage in the Commonwealth of Pennsylvania or the state of their residence,

(d) both partners are at least 18 years old,

(e) the partners are financially responsible for each other's well-being and debts to third parties, and can provide documentation of such responsibility; both partners have entered into a contractual commitment for that responsibility, or both have joint ownership of significant assets (such as home, car, bank accounts) and joint liability for debts (such as mortgages and major credit cards).

A dependent child is defined as:

a)    a child who is under age 26 (coverage is provided through age 25),

and

b)    the covered employee's or retiree's biological child; step-child; legally-adopted child; child legally placed for lawful adoption; “eligible foster child”, defined as a child placed with the employee or retiree by an authorized placement agency or by judgment, decree, or other order of any court of competent jurisdiction; or the child of the employee's or retiree's same-sex Domestic Partner.

An eligible dependent child who is mentally or physically incapable of earning a living and chiefly dependent on the covered employee or College retiree for support (the employee or retiree provides over half of the child's financial support) will continue to be eligible for coverage through the Health Plan beyond age 25, provided that the onset of incapacity occurred before the age of 19. The Plan Administrator and third party administrator reserve the right to request verification of disability.

Coverage is not provided through the Group Health Plan to an employee’s or retiree’s grandchild(ren); to the spouse or children of an employee’s or retiree’s adult child; or to other relatives not listed above.

The Plan Administrator and the third party administrator reserve the right to require verification of dependent status (such as a marriage or birth certificate, a copy of the most recent tax return, a copy of a court order, etc.) before approving coverage for a dependent.  Such verification must be provided to the Human Resources office before a dependent may be enrolled in the Health Plan.

Enrollment

Eligibility for coverage for employees classified as “full-time” begins the first day of the calendar month following, or coinciding with, appointment to a regular full-time position in an eligible class as described above.  

An eligible employee must submit a properly completed enrollment form within 31 calendar days of the first day of eligibility, in order to be enrolled in the Plan.

If an enrollment form is not completed and returned to the Plan Administrator (via the Franklin & Marshall College Human Resources office), the employee will be deemed to have declined coverage through the Health Plan.

If the enrollment form is not submitted to the Plan Administrator (via Human Resources) within 31 calendar days of the first day of eligibility, coverage through the Plan shall become effective no sooner than the next January 1, barring any special enrollment rights and assuming an enrollment form is completed and returned by January 1.

If an eligible employee or College retiree has previously opted-out of the Plan, he/she may enroll by completing and submitting an enrollment form during the annual Open Enrollment period, which begins each November on the date announced by the Plan Administrator and ends each December on the date announced by the Plan Administrator, with coverage effective the next January 1.

Providing a Plan participant and his/her covered dependent(s) remain eligible for coverage, coverage will continue until the participant completes and submits the proper form to terminate coverage. Employees and retired employees will be required to pay their applicable share of premiums, which may vary from year-to-year, to continue their coverage.

An employee or College retiree and each of his/her covered dependents must enroll in the same health plan option.

Before enrolling a same-sex Domestic Partner, and child(ren) of a same-sex Domestic Partner, a Certification of Same-sex Domestic Partnership (available from Human Resources and in the Human Resources public folder in eDisk) must be completed by the employee or retiree and his/her same-sex Domestic Partner, and returned to the Plan Administrator (Human Resources). If an employee's or retired employee's covered Domestic Partner is no longer eligible for coverage because he/she no longer qualifies as a Domestic Partner per the College's Domestic Partner Policy, the Plan participant may not cover another Domestic Partner as a dependent for a period of 12 months from the date benefit coverage terminated for the previous Domestic Partner.

Failure to Enroll

If an employee who is eligible for health coverage through the Plan fails to complete and return the proper enrollment form to the Plan Administrator (via Human Resources) within 31 calendar days of his/her initial date of eligibility, the employee shall be deemed to have elected not to participate and receive benefits through the Plan.

Opting-out-- An employee or retiree may elect not to participate in the Plan by returning the enrollment form to the Plan Administrator (Human Resources), within 31 calendar days of his/her initial date of eligibility, stating that he/she elects to "opt-out".

If an employee or retiree fails to re-enroll during the Open Enrollment period and is still eligible to participate, the employee or retiree shall be deemed to have elected to remain enrolled in the same health plan option as in effect for such participant during the immediately preceding Calendar Year. The applicable premium for the current Calendar Year will be required, and benefits and coverage levels will be based on the plan design for the current Calendar Year.

An employee or retiree who is not a Plan participant and fails to complete and submit an enrollment form during the Open Enrollment period shall be deemed to have elected not to receive benefits through the Plan.

Changes in Status / Special Enrollment Periods / “Mid-year” Election Changes

Generally, an employee or College retiree may add a dependent(s) to his/her health coverage through the Plan, or delete a dependent(s) from coverage, and make other election changes only once per year, during the annual Open Enrollment period, with the change effective the next January 1.

Changes to Plan elections may only be made after the start of the Calendar Year (January 1), and for the balance of the Calendar Year, if:

  • a participant experiences a "Change in Status", as defined by the Internal Revenue Service, that affects eligibility for coverage (see below)
  • an employee or retiree, spouse, or dependent becomes qualified for, or loses, coverage under Medicare or Medicaid or under the Children’s Health Insurance Program (CHIP); or if it is determined that the employee, spouse, or dependent is eligible for premium assistance under Medicaid or CHIP
  • an employee or retiree or dependent qualifies for special enrollment rights under the Health Insurance Portability and Accountability Act (HIPAA): an individual who is otherwise eligible for health coverage through the College's Health Plan, but declined coverage because he/she had other health insurance coverage, is permitted to enroll in the College's Plan upon loss of eligibility for other coverage or upon termination of "COBRA" coverage under another employer's plan; an eligible individual may enroll in the College's Plan if his/her employer's contributions toward other coverage cease; and an employee or retiree may enroll him/herself and eligible dependents following marriage, birth of a child, adoption, or placement for adoption. Loss of eligibility for coverage may occur (1) when an individual meets the lifetime maximum benefit level under another employer's health plan, or (2) when the other employer no longer offers any benefits to a class of similarly-situated individuals.
  • an employee takes an unpaid leave of absence per the Family & Medical Leave Act
  • an employee's or retiree's spouse or dependent child makes permissible election changes under his/her employer's health plan, such as during an Open Enrollment period
  • a benefit option is significantly curtailed: when the Plan Administrator determines that the coverage for an employee or retiree, spouse, or dependent child has been "significantly curtailed" with or without a loss of coverage, the employee or retiree can revoke the current election and must elect coverage under a similar benefit option. However, if the employee or retiree, spouse, or dependent experiences a loss of coverage as a result of the curtailment, the participant has the option of not electing replacement coverage under the Plan. Whether there has been a loss of coverage or a significant curtailment in coverage will be determined in the sole discretion of the Plan Administrator, and applied on a consistent basis. A loss of coverage may occur when there is a substantial decrease in the providers who participate in a benefit option or if there is a reduction in benefits for a specific medical condition for which the employee or retiree, spouse, or dependent is currently under treatment. Coverage is considered to be "significantly curtailed" only if there is an overall reduction in coverage.
  • a benefit option is added or significantly improved: when the Plan adds a new benefit option or significantly improves an existing option, the Plan Administrator may permit participants to make an election change to participate in the new or significantly improved option, on a prospective basis, and to revoke their elections under any similar benefit option. The Plan Administrator, in its sole discretion and applied on a consistent basis, will determine whether there has been an addition of or significant improvement in a benefit option.
  • an employee or retiree, spouse, or dependent or a benefit option under the Plan experiences a relevant, significant change in cost: if the Plan Administrator determines that the cost charged to an employee or retiree for a specific benefit option has significantly increased, the employee or retiree can revoke his/her election for that coverage and elect coverage under another benefit option. If the Plan Administrator determines that the cost charged to an employee or retiree for a specific benefit option has significantly decreased, an employee or retiree may revoke any existing elections and elect coverage under the option with the cost decrease. The Plan Administrator, in its sole discretion and on a uniform and consistent basis, will determine whether a cost increase or decrease is significant based on IRS guidance.

or

  • the Plan receives a court order, such as a Qualified Domestic Relations Order or Qualified Medical Child Support Order, requiring the College's Health Insurance Plan to provide coverage for a dependent(s)

Each of the following qualifies as a "Change in Status" based on current Internal Revenue Service regulations:

  • a change in marital status due to marriage, death of a spouse, divorce, legal separation, or annulment
  • a change in number of dependents due to birth, death, adoption, or placement for adoption
  • a change in employment status due to commencement or termination of employment, commencement of or return from unpaid leave of absence, a change in work site by the employee or dependent, or other change in employment that leads to a loss or gain of eligibility of the employee, spouse, or dependent under a plan
  • a change in a dependent's ability to satisfy the requirements for coverage due to attainment of age 26
  • a change in the place of residence or work of the employee or retiree, spouse, or dependent that affects eligibility for coverage

Any mid-year election change(s) must be on account of and consistent with the status change experienced by the employee or retiree.

Additional Information Regarding Mid-year Election Changes:

  • Except in limited circumstances, benefit election changes made on account of a “Change in Status” as described above must be applied prospectively.
  • Other than in the case of birth, adoption, or placement for adoption, changes to benefit plan elections made on account of a status change will be effective the first of the calendar month following the status change. For example, if a College Health Plan participant marries on May 14, coverage for the new spouse will be effective on June 1, assuming the employee properly completes and submits a Health Plan enrollment form within 31 days of the June 1 eligibility date. However, if an employee gives birth on May 14, health coverage for the new dependent through the Plan will be effective as of May 14, if the employee properly completes and submits an enrollment form within 31 calendar days of the birth date (May 14).
  • Plan participants' pre-tax Health Plan premiums will automatically be adjusted, through the Insurance Premium Payment Plan, if there is an increase or decrease in the cost of coverage through the Group Health Plan. Such adjustments will be made prospectively.
  • A Plan participant may not cancel coverage for him/herself or a dependent upon becoming eligible for health insurance coverage through another plan unless the employee or dependent actually becomes covered through the other plan.
  • If an employee terminates employment and is then rehired by the College within 30 calendar days, he/she will not be permitted to change previous Health Plan and Flexible Spending Accounts elections, unless the employee has experienced another "Change in Status" or relevant event as described above.
  • Health coverage may not be cancelled by a participant if he/she experiences a "significant curtailment" or change in coverage that does not constitute a loss of coverage. Health Plan premiums for retroactive coverage may only be paid on an after-tax basis, except in the case of birth, adoption, or placement for adoption.

 Adding or Deleting Dependents

If an employee or College retiree experiences a "Change in Status" or other relevant event as described above, and wants to add an eligible dependent to his/her Health Plan coverage, notification to the Plan Administrator (via the Human Resources office) must be made by the end of the Enrollment Period.  The Enrollment Period is within 31 calendar days of the date an individual is first eligible for coverage, or 60 calendar days in the case of eligibility based on the determination that the Plan participant is eligible for premium assistance under Medicaid or CHIP. The employee or retiree must submit a completed Health Plan enrollment form to the Plan Administrator (via the Franklin & Marshall Human Resources office) within the Enrollment Period. 

As noted above, if an employee or retiree wants to add his/her newborn child, newly adopted child, or child placed for adoption to College Health Plan coverage, an enrollment form must be completed and submitted to the Plan Administrator (Human Resources) within 31 calendar days of the birth, adoption, or date of placement for adoption.  In the case of birth, adoption, or placement for adoption, the Enrollment Period is within 31 days of the birth, adoption, or placement for adoption.  In the event of other changes in status, such as marriage, the Enrollment Period is within 31 calendar days of the 1st of the month following the event.

If an eligible employee or College retiree declines coverage for him/herself or an eligible dependent(s) because of other health insurance coverage, the employee or retiree may be able to enroll him/herself and eligible dependents in the College’s Health Plan provided the appropriate enrollment form is completed and submitted within the Enrollment Period. If the form is properly completed and submitted to Human Resources within the Enrollment Period, Health Plan coverage for the dependent will be effective as of the first day of the month coinciding with or following the status change, except when a dependent is added due to birth, adoption, or placement for adoption; coverage in this case will be effective as of the date of birth or adoption. If the enrollment form is not submitted during the Enrollment Period, coverage or election changes will be effective the next January 1 if a proper enrollment form is submitted during the annual Open Enrollment period.

Employees and College retirees are required to notify the Plan Administrator (via Human Resources) of a "Change in Status" or other event that makes a dependent ineligible for coverage through the Plan. To delete a dependent from coverage, the employee or retiree must submit a Health Plan enrollment form to the Plan Administrator within 31 calendar days of the status change. The dependent's coverage will be terminated at the end of the calendar month in which the “Change in Status” occurs.

Note: Coverage will terminate at the end of the calendar month in which an event or status change occurs which makes an employee, retiree, or dependent ineligible for coverage, even if proper notice is not provided to the Plan Administrator within the required time period.  To the extent permitted by law, any claims incurred after a Plan participant becomes ineligible for coverage will be the sole responsibility of the former Plan participant. To be eligible for continued Health Plan coverage through "COBRA", written notice must be provided to the Plan Administrator (via Human Resources) within 60 calendar days of a "Qualifying Event" which results in loss of coverage through the Plan (see below).

 

Plan Costs

Benefits provided under the Group Health Plan, including medical, prescription drug, and vision benefits, are paid for by Franklin & Marshall College and employees, retired employees, and COBRA beneficiaries enrolled in the Plan.

Premiums-- Active, full-time faculty and professional staff employees (class A) and retirees in classes B and C pay a portion of an actuarially-determined “premium equivalent” each month for their coverage through the Health Plan, based on the health plan option selected and their coverage level. Retired employees in eligibility class D pay the full (100%) actuarially-determined premium equivalent each month, based on the plan option selected and their coverage level.

Required participant-paid premiums may vary from year-to-year, at the sole discretion of the Plan Administrator, Franklin & Marshall College. The Plan Administrator will determine and communicate required participant-paid premiums each year during the Open Enrollment period.

The Plan Administrator will treat as imputed income to an employee or College retiree the value of health and prescription drug coverage provided to an individual who qualifies for coverage as a dependent through the Plan, but is not considered a legal dependent based on federal or state regulations.  Any contribution by the employee or retiree for coverage for the dependent will be subtracted from the value of such coverage. Based on current federal regulations, the College must treat as imputed income to an employee or retired employee the value of coverage for his/her same-sex Domestic Partner and the partner’s children, unless the Domestic Partner and children qualify as the employee's or retiree's dependents under the Internal Revenue Code.

Premiums are deducted from a covered employee's pay in equal installments. Active employees are automatically enrolled in the Franklin & Marshall Flexible Spending Accounts Plan upon electing Group Health Plan coverage, which means each employee's share of costs is paid on a pre-tax basis through payroll deduction. Employees may elect to pay contributions, through payroll deduction, on an after-tax basis. To do so, an employee must notify the Plan Administrator (via Human Resources), annually and in writing, of his/her desire to make contributions on an after-tax basis. Such notice must be provided upon initial enrollment in the Plan, and during each annual Open Enrollment period.

Retired employees must submit their portion of costs to the Plan Administrator on an annual, semi-annual, quarterly, or monthly basis, no later than by the first day of the month when due.

Calendar year 2014 monthly participant-paid premiums for full-time faculty and professional staff (eligibility class A), retired employees enrolled through Medicare Parts A and B (eligibility class B), and employees who retired via the Phased Retirement Program for faculty or an approved early retirement program which provides Health Plan coverage (class C) are:

·              PPO Health Plan $1,000 + HRA--

(available only to active employees - eligibility class A)

   $71.17 per month for single coverage (employee only)

   $115.87 per month for the employee and one dependent

   $189.68 per month for the employee and two or more dependents

 

PPO Health Plan $300--  

$104.65 per month for single coverage (employee or retiree only)

$170.36 per month for the employee/retiree and one dependent

            $279.15 per month for the employee/retiree and two or more dependents

Year 2014 monthly participant-paid premiums for College retirees not yet eligible for Medicare benefits, and who did not retire via an approved Phased Retirement Agreement or other early retirement program (eligibility class D) are:

·      PPO Health Plan $300--

$631.50 per month for single coverage (retiree only)

$1,027.84 per month for the retiree and one dependent

$1,684.48 per month for the retiree and two or more dependents

Premiums required of a retired College employee and his/her dependent(s) are based on the eligibility class of the retired College employee, regardless of the Medicare-eligibility status of the retired employee's covered dependent(s).

Retired employees who are eligible for health coverage through Medicare, and their covered dependents who are eligible for coverage through Medicare, must enroll in Medicare Parts A and B on the earliest possible date following employment termination in order to retain coverage through the College’s Group Health Plan. Currently, there is no requirement that Medicare-eligible employees or retired employees enroll in a Medicare Part D prescription plan.

Other Costs

In addition to paying premiums, Plan participants pay deductibles, coinsurance, co-payments, and for Out-of-Network treatment, all charges above the “Provider’s Reasonable Charges” as determined by the third party administrator per the provisions of the benefit plan elected.

Retired employees enrolled through Medicare Parts A and B are also required to pay the applicable Medicare premiums per Medicare provisions.

Coinsurance-- Coinsurance is the percentage of eligible charges the Group Health Plan pays on behalf of a participant, after applicable deductibles and co-payments have been paid by the participant.

  • PPO Health Plan $1,000 + HRA, Network Care-- the coinsurance rate for most eligible charges is 100%, meaning the Plan pays 100% of medical care fees for covered services, after the participant has paid applicable deductibles and co-payments.  However, Plan participants pay 10% of billable charges, after paying the applicable deductible, for advanced imaging services performed on an outpatient basis, up to a maximum of $500 per person per year, or up to $1,000 per family per year for coinsurance.  “Advanced imaging services” are as defined in the Benefits Booklet.
  • PPO Health Plan $1,000 + HRA, Out-of-Network Care-- the Plan pays 70% of “Provider’s Reasonable Charge”, and the Plan participant is responsible for 30%, plus applicable deductibles, co-payments, and all charges above those deemed the Provider’s Reasonable Charge by the third party administrator.
  • PPO Health Plan $300, Network Care-- the coinsurance rate for eligible charges is 100%, meaning the Plan pays 100% of medical care fees for covered services, after the participant has paid applicable deductibles and co-payments.  However, Plan participants pay 10% of billable charges, after paying the applicable deductible, for advanced imaging services performed on an outpatient basis, up to a maximum of $500 per person per year, or up to $1,000 per family per year for coinsurance.  “Advanced imaging services” are as defined in the Benefits Booklet.
  • PPO Health Plan $300, Out-of-Network Care-- the Plan pays 70% of “Provider’s Reasonable Charge”, and the Plan participant is responsible for 30%, plus applicable deductibles, co-payments, and all charges above those deemed the Provider’s Reasonable Charge by the third party administrator.

“Provider’s Reasonable Charges”-- Provider’s Reasonable Charges are those determined by the third party administrator to be the reasonable fees received by similar physicians, hospitals, or other health professionals for the same service in the same geographic area. When a Plan participant receives treatment from an Out-of-Network health care provider, the Plan pays the Provider’s Reasonable Charge at the applicable coinsurance level. All charges above those deemed the Provider’s Reasonable Charge by the third party administrator are the responsibility of the Plan participant. Such amounts paid by a Plan participant do not count toward meeting deductibles or out-of-pocket maximums.

Deductibles-- Participants pay the following deductibles each calendar year before the Plan makes payments. The Health Plan deductible does not apply to / is not charged for physician's office visits (although tests, lab work, and outpatient procedures performed in conjunction with an office visit are subject to the deductible), prescription drug purchases, routine screening mammograms performed by a Network provider, emergency medical care in an emergency care facility, pediatric immunizations, covered vision services, and eligible preventive services and screenings as defined by the Patient Protection and Affordable Care Act of 2010 and performed by an In-Network- participating - provider.

  • PPO Health Plan $1,000 + HRA, Network Care-- $1,000 per calendar year for an individual and up to $2,000 per calendar year for the family
  • PPO Health Plan $1,000 + HRA, Out-of-Network Care-- $2,000 per calendar year for an individual and up to $4,000 per calendar year for the family
  • PPO Health Plan $300, Network Care-- $300 per calendar year for an individual and up to $600 per calendar year for the family
  • PPO Health Plan $300, Out-of- Network Care-- $750 per calendar year for an individual and up to $1,500 per calendar year for the family

Participant-paid co-payments, prescription drug co-payments, coinsurance, payments for vision care, and payments for ineligible services are not applied toward (do not count toward meeting) an individual’s Health Plan deductible.

Office Visit Co-Payments-- Participants pay the following co-payments per office visit to a health care provider. A co-payment is not charged when receiving eligible preventive services, as defined by the Patient Protection and Affordable Care Act of 2010, from an In-Network- participating – provider, when such services are the primary reason for the office visit.

  • PPO Health Plan $1,000 + HRA, Network Care-- $20 per visit to a primary care physician and $30 per visit to a specialist's office, including a chiropractor.  A $20 office visit co-payment applies to outpatient mental health care and outpatient substance abuse treatment.
  • PPO Health Plan $1,000 + HRA, Out-of-Network Care-- $0 (70% coinsurance rate applies)
  • PPO Health Plan $300, Network Care-- $20 per visit to a primary care physician and $30 per visit to a specialist's office, including a chiropractor.  A $20 office visit co-payment applies to outpatient mental health care and outpatient substance abuse treatment.
  • PPO Health Plan $300, Out-of-Network Care-- $0 (70% coinsurance rate applies)

Other Co-payments-- The following co-payments also apply to the PPO Health Plan $1,000 + HRA and to the Health Plan $300.  These co-payments are in addition to the deductible and any applicable coinsurance, and apply to each visit.

o   a $50 co-payment for each emergency room visit (waived if admitted to a hospital);

o   a $100 co-payment for each inpatient hospital stay ($750 if admitted to an Out-of-Network hospital);

Prescription Drug Co-Payments-- Participants in the Group Health Plan pay the following co-payments when prescription medicine is purchased from a participating pharmacy:

Participating Retail Pharmacy Co-payment for a One Month Supply-

  • Formulary Generic Medicine - 15% of the drug cost, with a $5.00 minimum and $15.00 maximum co-payment per prescription
  • Formulary Brand Name Medicine - 25% of the drug cost, with a $20.00 minimum and $50.00 maximum per prescription
  • Non-formulary Brand Name Medicine - 35% of the drug cost, with a $40.00 minimum and $70.00 maximum per prescription

Mail Order Co-payment for a 90-day Supply (purchased through the Medco mail order program)-

  • Formulary Generic Medicine - 15% of the drug cost, with a $10.00 minimum and $30.00 maximum per prescription
  • Formulary Brand Name Medicine - 25% of the drug cost, with a $40.00 minimum and $100.00 maximum per prescription
  • Non-formulary Brand Name Medicine - 35% of the drug cost, with a $80.00 minimum and $140.00 maximum per prescription

When purchasing prescription medicine from a participating retail pharmacy, a "one month" supply equals a 31-day supply. One co-payment will be charged per "one month" supply of medicine. When purchasing medicine through the mail order program, one co-payment will be charged for an up-to-90-day supply of medicine. 

"Formulary" medicines are those included on the Highmark Drug Formulary, which is available upon request and at no charge from the Franklin & Marshall Human Resources office and from the third party administrator (Highmark Blue Shield).

When purchasing a brand name drug for which a generic version exists, the Plan participant will pay the brand name co-payment plus an ancillary charge equal to the difference in cost between the brand name drug and the generic version.

Prescription drugs in selected classifications will only be dispensed through an exclusive pharmacy provider and are limited to the retail cost sharing provisions and the retail days’ supply.  These selected prescriptions may be ordered by a physician or other health care provider, or the Plan participant may submit the prescription directly to the exclusive pharmacy provider, which will deliver the prescription.  These drugs include:

·      Oncology-related therapies

·      Interferons

·      Agents for multiple sclerosis and neurological related therapies

·      Antiarthritic therapies

·      Anticoagulants

·      Hematinic agents

·      Immunomodulators

·      Growth hormones

Out-of-Pocket Maximum-- The out-of-pocket maximum is the maximum amount the Plan participant will be required to pay each calendar year for coinsurance charges. The Plan participant may incur additional charges (deductibles, co-payments, amounts over the Provider’s Reasonable Charge, and penalty fees) above and beyond the annual out-of-pocket maximum.

  • PPO Health Plan $1,000 + HRA, Network Care-- $500 per individual, up to $1,000 per family
  • PPO Health Plan $1,000 + HRA, Out-of-Network Care-- $3,500 per individual, up to $10,500 per family
  • PPO Health Plan $300, Network Care-- $500 per individual, up to $1,000 per family
  • PPO Health Plan $300, Out-of-Network Care-- $3,500 per individual, up to $10,500 per family

Additionally, effective January 2014, a Plan participant will pay up to $6,350 per calendar year for health plan co-payments, coinsurance, and deductibles, and up to $12,700 per year for a covered family.

The maximum annual (per calendar year) out-of-pocket expense for prescription drugs, applicable to each health plan option, is:

·      $1,500 per individual, up to $3,000 per family

Prescription drug out-of-pocket maximums are not coordinated with and are in addition to health care out-of-pocket maximums.

 

Coordination of Coverage with Other Plans

The Group Health Plan will coordinate coverage with other plans, including Medicare, as described in the Benefits Booklet. Generally, the College's Plan is considered the primary plan for active employees and their dependents who are not covered through another employer's plan. The Plan is generally the primary plan for any active employee covered through Medicare. The Plan is generally the secondary plan for a spouse covered by his/her employer, and for a retired employee eligible for coverage through Medicare. If two plans cover a dependent child, the plan of the parent whose birthday falls earlier in the calendar year is generally the primary plan (unless a court order requires that the other plan be primary).

A retired College employee who is eligible for coverage through the federal Medicare program, and his/her covered dependent(s), if applicable, who is eligible for coverage through Medicare, must enroll in Medicare Parts A and B on the earliest possible date when first eligible following termination of employment, in order to retain coverage through the College’s Group Health Plan. Currently, there is no requirement that retired employees enroll in a Medicare Part D prescription plan.  Retired College employees and their covered dependents pay premiums, co-payments, coinsurance, and deductibles as outlined above and per the Benefits Booklet.

Plan participants should refer to their Benefits Booklet for complete information regarding coordination of benefits.

 

Termination of Health Plan Coverage

An employee's or a College retiree's coverage through the Group Health Plan, and coverage for each of his/her dependents, will terminate when one or more of the following events occurs.  Coverage terminates at 11:59 p.m. on the last day of the calendar month in which the event(s) occurs, unless noted below.  

a)    employment termination, other than a bona-fide retirement as defined by Franklin & Marshall College policies

b)    loss of full-time employment status; failure to complete at least 30 hours of work per week for wages during the employment year; or other event which causes an employee to no longer be a member of an eligible class

c)     death of a covered employee or a retiree

d)    during a medical leave of absence: expiration of employer-paid sick leave benefits (salary continuation) or expiration of Family & Medical Leaven per the College’s policy, whichever occurs later

e)    a covered employee's last work day prior to commencement of an unpaid leave of absence, including disability leave, which does not provide for continued coverage (other than an approved Family & Medical Leave or other approved leave of absence which provides for continued coverage); coverage for a faculty member commencing a 6- or 12-month unpaid leave of absence will terminate at the end of the month immediately preceding the leave of absence

f)     completion of a 12 month leave of absence which provided continued health coverage and failure to return to an eligible class

g)    loss of eligibility per provisions outlined in the third party administrator’s Benefits Booklet and/or College policies, and/or loss of dependent status per the College's policies

h)    failure by a covered employee or College retiree to pay the required premium within 30 days of the date the premium became delinquent; coverage will terminate retroactive to the 1st of the calendar month in which the premium became due

i)      for a retired Plan participant and his/her covered dependent(s), coverage will terminate within thirty (30) days of the date the participant is first eligible for Medicare coverage if the Plan participant fails to enroll in Medicare Parts A and B

j)      termination of the Shared Services Health Plan or termination by the College of its participation in the Plan.

A covered dependent will no longer be eligible for coverage through the Health Plan if he/she fails to qualify as an eligible dependent. Coverage terminates at 11:59 p.m. on the last day of the calendar month in which the event(s) occurs which causes the dependent to no longer qualify as a dependent eligible for Group Health Plan coverage.

Please see the “COBRA” section below for important information about optional, temporary continuation of coverage through the Group Health Plan following a “Qualifying Event” that leads to loss of coverage.

 

Coverage and Benefit Denials and Claims Procedures

Benefit Denials-- The procedures Health Plan participants are required to follow to file a complaint or grievance pertaining to denial, by the third party administrator, of payment, benefits, or coverage are available to all Plan participants and beneficiaries, at no cost. These procedures are provided with the Benefits Booklet, which is furnished automatically to employees and retired employees upon enrollment, and is also available upon request, and at no charge, from the Plan Administrator and the third party administrator. Plan participants must follow the procedures described in the Benefits Booklet, and adhere to time limits, to appeal denial of a claim for payment or benefits.

If the Plan Administrator receives an incomplete claim, it will provide to the Participant or dependent who submitted the claim a description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary.  This notice will be provided within 5 days (or immediately for urgent claims).

Adverse Eligibility / Coverage Determinations-- The Plan Administrator is responsible for determining whether an individual is eligible for coverage under the Plan.  In the absence of a claim for benefits, the above described appeal process for benefit denials is not applicable.  If a claim for benefits is filed, in accordance with the proper Plan procedures, and the claim is denied because the individual is not eligible for coverage under the Plan, then the coverage determination will be handled in accordance with the Benefits Denial and appeals procedure outlined above and in your Benefits Booklet.

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.

 

Plan Amendment, Modification, and Termination

The Group Health Plan may be amended or terminated by Shared Services and/or Franklin & Marshall College at any time. No consent of any participant or beneficiary is required to terminate, modify, amend, or change the Plan.

Plan benefits, coverage levels, and required participant-paid contributions and other costs and Plan features are subject to change at the sole discretion of the College. Additionally, for retired employees and their dependents and COBRA participants and dependents, coverage and costs (including, but not limited to, participant-paid premiums, deductibles, and co-payments) are subject to change following termination of employment.

 

Required Notices

“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 Group Health 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 Group Health 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 Group Health 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 Group Health 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 Group Health 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 Group Health 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 Group Health 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 of health 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 premium equivalent), plus a 2% administrative fee.  Year 2014 monthly premiums are as follows:

·      PPO Health Plan $1,000 + HRA--

$613.92 per month for single coverage, $1,007.15 per month for the individual plus one dependent, or $1,664.63 per month for family coverage   

·      PPO Health Plan $300--

$644.13 per month for single coverage, $1048.40 per month for the individual plus one dependent, or $1,718.17 per month for family coverage

 

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, (717) 291-3995, 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.

 

The Patient Protection and Affordable Care Act of 2010 (PPACA)

Extension of Dependent Coverage Until Age 26-- Effective January 1, 2011, children of enrolled College employees, retired employees, and COBRA beneficiaries may remain covered through the Shared Services Group Health & Prescription Drug Plan through age 25.  Per provisions of the Patient Protection and Affordable Care Act, coverage will be provided through age 25 for children of College employees, retirees, and COBRA beneficiaries even if the child is not a full-time student, does not live with the parent, is not financially dependent on the parent, and/or is married (coverage is provided for the child, but not the child’s family members).

If a child’s coverage through the College’s Health Plan terminated prior to January 1, 2011, because the child did not meet the prior eligibility requirements, an employee, retired employee, or COBRA beneficiary may re-enroll the child if the child is under age 26.  Employees, retired employees, and COBRA beneficiaries have until January 31, 2011, to re-enroll a child who is under age 26 in the Group Health & Prescription Drug Plan.  If the child is re-enrolled by January 31, 2011, his/her coverage will be retroactive to January 1, 2011.  To re-enroll a child, the parent (College employee, retiree, or COBRA beneficiary) must submit a completed Group Health Plan Enrollment Form to the Human Resources office no later than by January 31, 2011.  For more information, please contact the Human Resources office at (717) 291-3902 or 291-3996.

Lifetime Limits No Longer Apply-- Effective January 1, 2011, the lifetime limit on the dollar value of benefits under the Shared Services Group Health & Prescription Drug Plan no longer applies.  Individuals whose coverage ended by reason of reaching a lifetime limit under the Plan are eligible to re-enroll in the Plan.  Individuals have 30 days from the date of this notice to request enrollment.  Individuals who are not currently enrolled in the Plan may enroll by completing a Group Health Plan Enrollment Form and submitting it to the Human Resources office.  For more information, please contact the Human Resources office at (717) 291-3902 or 291-3996.

No Primary Care Provider Designation Required-- To receive the highest level of coverage, participants in the Group Health & Prescription Drug Plan have the right to visit any In-Network primary care provider; a provider who participates in the third party administrator’s (Highmark Blue Shield) PPO network and who is available to accept you or your family members.  Children may visit a pediatrician who participates in the third party administrator’s (Highmark Blue Shield) PPO network and receive the highest level of coverage.

Plan participants do not need prior authorization from Highmark, Franklin & Marshall, or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional who participates in the Highmark Blue Shield PPO network and who specializes in obstetrics or gynecology.  The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.

Plan participants may receive services from providers who do not participate in the third party administrator’s network and will receive a lower level of coverage at the “Out-of-Network” level.

 

Coverage Under the Women's Health and Cancer Rights Act

The Women's Health and Cancer Rights Act of 1998 requires group health plans to notify plan participants and beneficiaries of certain benefits provided under the plan. The Shared Services Group Health Plan provides the following coverage to any Plan participant or beneficiary who is receiving Plan benefits for a medically necessary mastectomy:

1.     reconstruction of the breast on which the medically necessary mastectomy was performed;

2.     any necessary surgery and reconstruction of the other breast to produce a symmetrical appearance;

3.     the cost of prostheses (such as implants or special bras);

4.     treatment for physical complications of all stages of mastectomy, including lymph edemas, as determined in consultation with the attending physician and the patient.

This coverage will be subject to the same deductibles and co-payments that apply to mastectomies under the Plan's terms in effect at the time of treatment.

 

The Newborns' and Mothers' Health Protection Act of 1996

The Newborns' and Mothers' Health Protection Act of 1996 requires group health plans that provide coverage for hospital stays following childbirth to provide coverage for a minimum period of time. In general, hospital coverage for the mother and newborn must be provided for a minimum of 48 hours following delivery, or 96 hours following a cesarean section. Group health plans may not restrict benefits for a hospital stay in connection with childbirth for the mother or newborn to less than 48 hours following delivery, and less than 96 hours following a caesarean section, unless the attending provider, after consultation with the mother, discharges the newborn earlier. A group health plan cannot require that a provider obtain authorization from the plan or third party administrator for a length of stay not in excess of these periods, but precertification may be required to reduce out-of-pockets costs or to use a certain provider or facility. Also, under federal law, group health plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. The Plan provides coverage in compliance with The Newborns' and Mothers' Health Protection Act.

 

Health Insurance Portability and Accountability Act of 1996

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 pre-existing 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

Effective Date

This Notice is effective September 23, 2013

 Our Responsibilities

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.

Special Situations

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 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:

(1) the individual identifiers have been removed; or

(2) when an institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of the requested information, and approves the research.

Required Disclosures

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.

Other Disclosures

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:

(1) you have been, or may be, subjected to domestic violence, abuse or neglect by such person; or

(2) treating such person as your personal representative could endanger you; and

(3) in the exercise of professional judgment, it is not in your best interest to treat the person as your personal representative.

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.

Your Rights

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.

Complaints

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

(717) 291-3995

 

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 Group Health Plan coverage on the same terms and conditions as if the employee were still an active employee. During a paid leave under the FMLA, participation in the Group Health Plan will continue for an employee, and his/her covered dependents, who otherwise remains eligible, and who was covered through the Plan immediately prior to commencement of leave. Premium contributions, at active employee rates, will be deducted from the employee's salary on a pre-tax / salary reduction basis as permitted by law, unless the employee previously elected to have premiums deducted on an after-tax basis.

During an unpaid leave under the FMLA, an employee may elect to continue or may discontinue coverage under the Group Health Plan, and/or the Medical Expense Reimbursement Account of the Flexible Spending Accounts Plan.

An employee who is entitled to and takes an unpaid leave of absence under the FMLA and elects to continue coverage under the Plan while on FMLA leave must pay his/her share of the premiums for such coverage. Payments are to be made by the employee in one of the following ways:

Pre-payment Option-- an election by the employee to pre-pay all or a portion of the premiums due during the FMLA leave period on a pre-tax basis through salary reduction of not yet available pre-leave compensation, to the extent that such pre-tax payments will not be used to fund coverage during the next Calendar Year. If an employee elects this pre-payment option, he/she must notify the Plan Administrator, via the Franklin & Marshall Human Resources office, at least one month in advance of commencement of leave. Pre-payment cannot be required as a condition of remaining in the Plan, nor can it be the only method available for paying premiums for coverage during an FMLA leave.

Pay-As-You-Go Option-- an arrangement under which the employee pays his/her share of health contributions on an after-tax basis by sending the payments to the College. Health premiums, at active employee rates, must be paid by the employee on a monthly basis and submitted to the Plan Administrator, via the Franklin & Marshall Human Resources office. Each monthly payment is due by the last work day of the month. If premium payments are more than 30 calendar days late, College health coverage will be terminated during the remainder of the leave.

If the employee elects to continue his/her coverage while on unpaid leave, the College will continue to pay its share of any premiums. If an employee's coverage ceases while on FMLA leave, upon return from such leave, he/she may elect to be reinstated in the Plan on the same terms that applied prior to the employee's FMLA leave, or as otherwise required by the FMLA.

 

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.

 

Qualified Medical Child Support Order

Procedures for determining whether a medical child support order is a "Qualified Medical Child Support Order" are available from the Plan Administrator (via the Franklin & Marshall Human Resources office) upon request, and at no charge.

 

"CHIPRA" Special Enrollment Rights Notice

Many states, including Pennsylvania, provide health care coverage to uninsured children if the family’s income falls below a certain level.  These programs are known as the Children’s Health Insurance Program (CHIP).  Effective February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) was signed into law.  Through CHIPRA, a state CHIP may elect to offer premium assistance to subsidize employer-provided health care coverage for eligible low-income children and families.  You can find information about Pennsylvania CHIP, including eligibility guidelines, enrollment information, and information about premium assistance, at http://chipcoverspakids.com/; by calling (800) 986-KIDS; from http://www.dpw.state.pa.us/hipp; or by calling (800) 692-7462.

CHIPRA requires health plan sponsors, such as Franklin & Marshall College, to notify employees of a special health plan enrollment period.  Ordinarily, full-time College employees may enroll in the Franklin & Marshall Group Health & Prescription Drug Plan only during the annual "open enrollment" period, with coverage effective the following January 1. Employees and their eligible dependents may enroll in the health plan at other times during the year only in limited circumstances, such as following marriage, birth or adoption of a child, or loss of other health insurance coverage.

Franklin & Marshall permits employees and their dependents who are eligible for health care coverage but are not enrolled through the College's Group Health & Prescription Drug Plan to enroll in the plan within 60 calendar days of either of the following events:

  1. The employee's or dependent's Medicaid or CHIP coverage is terminated as a result of loss of eligibility.

or

  1. The employee or dependent becomes eligible for a premium assistance subsidy under Medicaid or CHIP.

A College employee must request to enroll in the Franklin & Marshall Group Health & Prescription Drug Plan within 60 calendar days of the loss of Medicaid or CHIP coverage, or within 60 calendar days of when determined to be eligible for a premium assistance subsidy under Medicaid or CHIP.  (Eligible employees may also enroll during any open enrollment period.)       

If you or a dependent qualifies for this special enrollment period, please contact a Human Resources Administrator, Human Resources, CSQ, (717) 291-3995.  You must complete and return a Franklin & Marshall Group Health Plan enrollment form within 60 calendar days of loss of Medicaid or CHIP coverage or of becoming eligible for premium assistance through Medicaid or CHIP.  You will need to provide verification to Human Resources of loss of coverage through Medicaid or CHIP, or verification that you are eligible for a premium assistance subsidy under Medicaid or CHIP.

If you live outside of Pennsylvania and would like to determine whether another state offers a premium assistance program / CHIP, or for more information regarding special enrollment rights, you may contact either the:

U.S. Department of Health and Human Services    

Centers for Medicare & Medicaid Services

www.cms.hhs.gov                                         

(877) 267-2323, ext. 61565

U. S. Department of Labor

Employee Benefits Security Administration

www.dol.gov/ebsa

 

Medicare Prescription Drug Creditable Coverage Disclosure Notice; Important Notice From Franklin & Marshall College About Your Prescription Drug Coverage and Medicare

This Notice has information about current prescription drug coverage through Franklin & Marshall College and prescription drug coverage available for individuals with Medicare coverage.  It also explains the options you have under Medicare prescription drug coverage and can help you decide whether or not to enroll in a Medicare prescription drug plan.  If you are considering enrolling in a Medicare prescription drug plan, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area.  At the end of this Notice is information about where you can get help to make decisions about your prescription drug coverage.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1.     Medicare prescription drug coverage became available in 2006 to everyone with Medicare health coverage. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 

2.     Franklin & Marshall College has determined that the prescription drug coverage offered through the College’s Shared Services Group Health & Prescription Drug Plan is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered “Creditable Coverage”.

Because your existing coverage through the Franklin & Marshall prescription drug plan is on average at least as good as standard Medicare prescription drug coverage (“Creditable Coverage”), you can keep this coverage as long as you are eligible for coverage through the Franklin & Marshall College Group Health & Prescription Drug Plan.  You will not pay a higher premium (a penalty) if you later decide to enroll in Medicare prescription drug coverage.

When Can You Join A Medicare Drug Plan?-- Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare, and each year from October 15 through December 7.  However, if you lose other “creditable” prescription drug coverage, through no fault of your own, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Part D Medicare prescription plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?-- If you are retired and enroll in both the Franklin & Marshall Group Health & Prescription Drug Plan and a Medicare-approved prescription drug plan, the College’s plan will be the secondary payment provider.  You will pay the applicable monthly Medicare premium plus the premium required to be covered through the College’s plan.  Please contact Franklin & Marshall’s Human Resources office, at (717) 291-3995, if you would like more information about what happens to your coverage if you enroll in a Medicare prescription drug plan.

You should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area.  If you do decide to enroll in a Medicare prescription drug plan and drop your Franklin & Marshall prescription drug coverage, be aware that you and your dependent(s) may not be able to enroll again in the Franklin & Marshall Group Health & Prescription Drug Plan until the next Open Enrollment period, with coverage effective the following January 1.  To re-enroll in the College’s plan, you must complete and submit an enrollment form to Human Resources, Franklin & Marshall College, in a timely manner.

Please note, if you terminate your prescription coverage through the Franklin & Marshall Group Health & Prescription Drug Plan, you and your dependents will no longer be eligible for any hospitalization, medical, vision, or prescription drug coverage through the College.  You may, however, re-enroll in the Franklin & Marshall Group Health & Prescription Drug Plan during any Open Enrollment  period, with coverage effective the next January 1, providing you and your dependents remain eligible for such coverage.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?--

You should also know that if you drop or lose your current coverage through the Franklin & Marshall Group Health & Prescription Drug Plan and do not join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.  

If you go 63 continuous days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly premium will go up at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage.  For example, if you go 19 months without coverage, your premium will always be at least 19% higher than what many other people pay.  You’ll have to pay this higher premium as long as you have Medicare prescription drug coverage.  In addition, you may have to wait until the following November to enroll.

 

For more information about this Notice or your current prescription drug coverage:

Please contact the Franklin & Marshall Human Resources office at (717) 291-3995 if you would like more information.  Note:  You will receive this Notice annually and at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if prescription drug coverage through Franklin & Marshall changes.  You also may request a copy from the Human Resources office at any time.

 

For more information about your options under Medicare prescription drug coverage:

More detailed information about Medicare plans that offer prescription drug coverage is available in the Medicare & You handbook. You will receive a copy of this handbook in the mail every year from Medicare.  You may also be contacted directly by Medicare prescription drug plans.  For more information about Medicare prescription drug plans:

·      Visit www.medicare.gov

·      Call your state Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number)

·      Call 1-800-MEDICARE - (800) 633-4227.  TTY users should call (877) 486-2048.

For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available.  Information about this extra help is available from the Social Security Administration, (800) 772-1213 (TTY (800) 325-0778), www.socialsecurity.gov.

Remember: Keep this notice. If you enroll in one of the plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium. You may contact Human Resources if you need another copy.

 

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 Group Health 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 Group Health 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 Group Health Plan, you should contact the Plan Administrator, via the Franklin & Marshall College Human Resources office. 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 Plan 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 and the Benefits Booklet and Summary of Vision Benefits have been complied with and exhausted.

 

The Health Reimbursement Account is available to those who enroll in the PPO Health Plan $1,000 (the High Deductible / Low Premium health plan).

Health Reimbursement Account

Summary Plan Description

This Summary Plan Description ("SPD") describes the Health Reimbursement Account available under the Franklin & Marshall College Group Insurance Plan and Flexible Spending Account (the Health Reimbursement Account is described herein as the "HRA Plan" or the "Plan"), effective as of January 1, 2014. The benefits available under this Plan are closely connected to the benefits that you are eligible for under the plan identified as the “PPO Health Plan $1,000 + HRA”, a high deductible health plan (the "PPO Health Plan $1,000") and offered through the Shared Services Group Health Plan (“Group Health Plan”).  Copies of the Summary Plan Description for that plan are available upon request, by contacting the Franklin & Marshall Human Resources department. This is not a Certificate of Insurance. It 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 Plan, 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 SPD as accurate as possible. However, in the event of a discrepancy between this SPD and the Plan Document, the Plan Document shall control. The Plan Document can be viewed by contacting Human Resources, (717) 291-3995. The Plan is established for the benefit of employees and their covered dependents and is administered impartially for the benefit of all eligible participants.

Note: The information in this Summary Plan Description applies to Franklin & Marshall employees who enroll in the College’s PPO Health Plan $1,000, and to former Franklin & Marshall PPO Health Plan $1,000 participants with a remaining balance in the Health Reimbursement Account.
 

Facts about the Plan

Plan Name: Franklin & Marshall College Group Insurance Plan and Flexible Spending Account

Plan Number: 501 - Plan 501 also includes the Shared Services Group Health Plan, the Franklin & Marshall Group Dental Plan, the Franklin & Marshall College Group Life Insurance Plan, and the Franklin & Marshall College Flexible Spending Accounts 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.

Named Fiduciary: Franklin & Marshall College, Lancaster, PA 17604-3003

Plan Sponsor's Employer Identification Number: 23-1352635

Original Plan Effective Date: January 1, 2007

Plan Year: January 1 through December 31

Type of Plan: Welfare plan providing reimbursement for health care expenses

Plan Administrator: Franklin & Marshall College, P.O. Box 3003, Lancaster, PA, 17604-3003

Claims Administrator / Type of Administration:  Administration is provided through an independent third party administrator. The third party administrator is Significa Benefit Services, P.O. Box 7777, Lancaster, PA 17604-7777.  Significa Benefit Services’ telephone numbers are (717) 581-1300 and (800) 433-3746. Significa Benefit Services is appointed by the College to perform certain administrative services with respect to the Plan.  Significa Benefit Services does not finance or insure the Plan. Under this type of administration, benefits are not guaranteed under a contract or policy of insurance. In its role as a third party administrator, Significa Benefit Services is not an "administrator" as defined in Section 3(16)(A) of ERISA. The College is the Plan "administrator" as defined in Section 3(16)(a) of ERISA.

Agent for Service of Legal Process: Director, Human Resources, Franklin & Marshall College, P.O. Box 3003, Lancaster, PA, 17604-3003.

Funding: Benefits are paid for through the general assets of the employer; participants are not required to contribute to this Plan
 

Plan Benefits

Health Reimbursement Account

Eligible College employees who elect to participate in the PPO Health Plan $1,000 will participate in this Health Reimbursement Account Plan. The College will make a contribution to each participating employee's Health Reimbursement Account (HRA). Participating employees may then request reimbursement from their Health Reimbursement Account for their, and their eligible dependents', health care expenses as described below in the section titled "Eligible Expenses". The maximum amount a participating employee may be reimbursed from the HRA is the full eligible expense incurred by the employee or incurred by the employee's dependent(s) who is enrolled in the PPO Health Plan $1,000, or the employee's full, current HRA balance, whichever is less.

Funds will be credited to each participating employee's Health Reimbursement Account (HRA) on January 1st of each calendar year. The amount credited to each HRA will be based upon the schedule distributed by the College and communicated to employees each year during the Open Enrollment period, and will be based on the coverage level elected by the participating employee.

At the end of the Plan Year (December 31) any amount remaining in an employee's HRA will carry over to the next Plan Year, as long as the employee remains enrolled in the PPO Health Plan $1,000 with Health Reimbursement Account. As of January 1, each participating employee will be eligible to receive the College's full HRA contribution for that Plan Year, regardless of his/her current HRA balance.

Any unused funds remaining in an employee's HRA upon termination of the employee's participation in this Plan will be forfeited by the employee, except as described below in the "Termination of Coverage" section. Therefore, an employee who elects to discontinue participation in the PPO Health Plan $1,000 with Health Reimbursement Account at the start of a new Plan Year or during the year will forfeit the full balance in his/her HRA.

Plan participants whose College employment terminates, other than as described below in the "Termination of Coverage" section, will forfeit their entire unused HRA balance upon termination of eligibility for participation in this Plan, except as described below in the section titled "Continuation of Coverage through COBRA ". Funds will be retained by the College to offset future expenses.

Plan participants who qualify to retain their HRA balance upon retirement or termination as described below may request reimbursement, during retirement, for qualified medical expenses.  Reimbursements from the HRA are tax-free to the former employee, if used to pay qualified medical expenses as defined by the IRS.


Eligibility for Coverage

The following classes of employees, and their eligible dependents, are eligible for coverage under this Plan:

Class A:

  • 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; the current, actively employed Spectrometer Technician; 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 or Pre-retirement Leave of Absence Agreement
  • full-time faculty who have been granted a leave of absence to further their scholarship and/or teaching and who receive a stipend from a competitive grant or fellowship that does not provide health insurance coverage, upon approval of the Provost and Dean of the Faculty (eligibility for coverage may continue for the time period covered by the grant or fellowship, not to exceed 12 months)
  • full-time faculty on an approved paid sabbatical or paid Junior Faculty Leave, not to exceed 12 months
  • 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, not to exceed 12 months

To participate in the HRA Plan, the employee and any covered dependents must be eligible for coverage and enrolled in the College's PPO Health Plan $1,000. 

Coverage is provided for the eligible employee; the employee plus one dependent; or the employee plus two or more dependents.

Independent contractors, contracted employees, adjunct faculty, individuals who volunteer their services without compensation, students, student employees, former employees and retired members of the College faculty and professional staff, and those not in a covered class are not eligible for coverage through the Plan.


Eligible Dependents

For purposes of the HRA Plan, eligible dependents include any dependents who are enrolled with the employee in Franklin & Marshall College's PPO Health Plan $1,000 as dependents, including a same-sex Domestic Partner as defined by the College's policies. If an employee enrolls his/her same-sex Domestic Partner, the College will deduct from the employee's salary the imputed value of the partner's coverage under this HRA Plan, as required by federal, state, or local law.

Dependents must be enrolled in the College's PPO Health Plan $1,000 to be eligible for coverage under this HRA Plan and to be reimbursed for their eligible expenses.

Employees, spouses / same-sex Domestic Partners, and dependent children who are participating in a Health Savings Account (HSA) are not eligible for coverage under this Plan.


Enrollment

Eligibility for coverage for employees under this HRA Plan coincides with the employee's enrollment in the PPO Health Plan $1,000 sponsored by the employer. College employees are initially eligible to enroll in the PPO Health Plan $1,000 as of the first day of the month coinciding with, or following, appointment to a full-time position in an eligible class as described in the Shared Services Group Health Plan Summary Plan Description (available from the Plan Administrator via the Human Resources office). Eligible employees may also elect to enroll in the PPO Health Plan $1,000 during any Open Enrollment period, with coverage effective the next January 1.

Enrollment in this Plan is automatic upon an eligible employee's enrollment in the PPO Health Plan $1,000 and does not require a separate election or enrollment form. The PPO Health Plan $1,000 is the health plan designated by the College to include a high deductible and to include a health reimbursement account. Information regarding the PPO Health Plan $1,000 may be found in the Shared Services Group Health Plan Summary Plan Description, or by contacting the Human Resources department, (717) 291-3995.


Changes in Status / Special Enrollment Periods / “Mid-year” Election Changes

Generally, an employee may add a dependent(s) or delete a dependent(s) from coverage only if a corresponding change is made to the employee's coverage under the PPO Health Plan $1,000. Changes to coverage under this HRA Plan will occur automatically when changes are made to the employee's coverage under the PPO Health Plan $1,000. The Plan Administrator may modify enrollment elections for administrative purposes or to comply with Plan legal requirements. Employees are permitted to change their health plan elections after January 1 and, hence, elections under this Plan only in limited situations. Employees are encouraged to review the Shared Services Group Health Plan Summary Plan Description for information about making changes to coverage after January 1. The Summary Plan Description may also be obtained by contacting the Human Resources department, (717) 291-3995.

If an employee enrolls in the HRA Plan after the start of the Plan Year (as permitted under the terms of this Plan and the PPO Health Plan $1,000), the entire designated amount will be credited to the employee's HRA for the Plan Year. The amount will not be pro-rated.

If an employee adds dependents to his/her coverage during a Plan Year (as permitted under the terms of this Plan and the PPO Health Plan $1,000), the HRA will be increased to reflect the contribution amount for the employee's new coverage level. If an employee drops one or more dependents from coverage during a Plan Year (as permitted under the terms of this Plan and the PPO Health Plan $1,000), his/her HRA balance will not be changed or decreased as a result of the change in coverage level.


College-funded Annual Health Reimbursement Account Contribution

The College currently contributes the following amount per participating employee:

  • $420.00 total for employees electing single coverage through the College's PPO Health Plan $1,000
  • $840.00 total for employees covering self plus one dependent through the College's PPO Health Plan $1,000, or
  • $1,260.00 total for employees covering self plus two or more dependents through the College's PPO Health Plan $1,000

The amounts above reflect the annual contribution per participating employee, not per covered dependent.

A participating employee's full HRA balance will be available to him/her as of January 1.

The annual College-funded contribution to participants' Health Reimbursement Accounts may vary from year to year, and will be communicated to employees during the annual Open Enrollment period prior to the beginning of each Plan Year.

Each employee participating in the PPO Health Plan $1,000 with Health Reimbursement Account will receive the full applicable College-provided contribution to his/her HRA as of January 1, regardless of his/her current HRA balance.


Eligible Expenses

Health Reimbursement Account funds are provided to participating employees to help off-set the annual deductible incurred under the PPO Health Plan $1,000.  Effective January 1, 2014, eligible expenses also include health and prescription drug co-payments and health and prescription coinsurance (including the deductible, co-payments, and coinsurance for eligible, covered family members) applicable under the PPO Health Plan $1,000. Health Reimbursement Account funds are available to reimburse only those expenses incurred to pay the annual deductible, co-payments, and coinsurance under the PPO Health Plan $1,000.

Eligible expenses must be incurred during the Plan Year (from January 1 through December 31) in which the employee participates in the Plan. An employee may not request reimbursement from his/her HRA balance for expenses incurred during a prior Plan Year, except that employees have until March 31 of the next Plan Year to submit a claim for reimbursement pertaining to the prior year. Expenses are treated as having been incurred when the employee or eligible dependent is provided with the service that gives rise to the expense, not when the participant is formally billed for, or pays for, the service.

Expenses are only eligible for reimbursement when the employee, spouse, and/or dependent child who incurred the expense is covered under the Franklin & Marshall PPO Health Plan $1,000 with Health Reimbursement Account.


Submitting a Claim for Reimbursement

Each employee will be entitled to receive, upon submitting a claim, reimbursement from the Claims Administrator for incurred, eligible expenses under the PPO Health Plan $1,000, up to the amount designated for the employee's Health Reimbursement Account less any prior reimbursements. Therefore, the maximum amount an employee may be reimbursed from the HRA is the lesser of (a) the full eligible expense incurred by the employee or his/her covered dependent, or (b) the employee's current, full HRA balance.

An employee may not "borrow" from his/her future anticipated HRA balance, or be reimbursed for an expense incurred during a previous Plan Year from the current year’s HRA balance.

When a Plan participant (College employee) has incurred eligible health care expenses, the participant may either pay for such expenses using the Plan debit card, or may pay with a personal credit card, check, or cash and then submit a Claim Form to request reimbursement from his/her HRA.

Debit Card--  A Plan participant may pay for eligible health care expenses with a Plan debit card, in lieu of submitting a Claim Form to request reimbursement.  The eligible expense will then be deducted from the participant’s Health Reimbursement Account balance.  After paying with the debit card, the Plan participant may be required to provide substantiation of the health care expense (such as an itemized receipt from the health care provider and an Explanation of Benefits from the health plan administrator).   The Plan Administrator will notify the participant if substantiation is required.  Use of the debit card is optional; a Plan participant may choose instead to pay the expense with a personal credit card, by check, or with cash and then submit a Claim Form to request reimbursement.

The HRA Claim Form is available in the Human Resources office, via eDisk (Human Resources public folder), and from Significa Benefit Services. If not paying for eligible health care expenses with the debit card, a properly completed Claim Form must be submitted to the Claims Administrator (Significa Benefit Services) along with an itemized bill and "Explanation of Benefits" (EOB) indicating the name and address of the health care provider, the name of the individual receiving services, date of services, type of services, and the amount charged for services.

The Claims Administrator will provide reimbursement to the participating employee for eligible expenses from the employee's current Health Reimbursement Account balance. Reimbursement for eligible expenses will be sent directly to the participating employee, not to the employee's health care provider or the health plan insurance provider.

All claims must be filed within three (3) months after the end of the Plan Year (by March 31 of the following calendar year), or within three (3) months after coverage terminates under this Plan. To receive reimbursement for eligible expenses, a properly completed and substantiated claim must be submitted by the Plan participant to the Plan's Claims Administrator (Significa Benefit Services) no later than by March 31 of the following Plan Year, or within 3 months after coverage under the Plan terminates (i.e., the claim must be postmarked no later than by March 31 of the calendar year following the end of the Plan Year, or submitted via fax or hand-delivered to the Claims Administrator by March 31, or postmarked or submitted via fax within 3 months after coverage terminates).

Cancelled checks presented without other required documentation are not an acceptable form of claims substantiation.

The Claim Form and additional information listed above must be submitted directly to Significa Benefit Services, P.O. Box 7777, Lancaster, PA 17604-7777, fax (717) 581-8379.


Year-end HRA Balances

Any unused funds remaining in an employee's HRA at the end of the Plan Year will remain in the employee's account for as long as the employee remains enrolled in the PPO Health Plan $1,000. At year end (December 31), all unused funds in an employee's HRA will carry forward to the next Plan Year, if the employee is eligible and elects to participate in the PPO Health Plan $1,000 with Health Reimbursement Account for that Plan Year.  Interest is not earned on the HRA balance.

Plan Costs

All benefits paid under this HRA Plan are payable directly to the employee out of the general assets of the employer. The employer will not establish a trust or fund for payment of benefits under this Plan. Employees are not required to contribute to the cost of coverage under this HRA Plan (however, employees are required to contribute to the cost of insurance coverage through the PPO Health Plan $1,000; participants should see the Shared Services Group Health Plan Summary Plan Description for contribution rates or contact the Human Resources department).

Coordination of Benefits

This Plan will provide benefits solely for eligible expenses that are not reimbursed or reimbursable elsewhere, except as noted below.

Coordination between the Health Reimbursement Account and the Medical Expense Reimbursement Account-- If a College employee participates in both the Medical Expense Reimbursement Account through the Franklin & Marshall College Flexible Spending Accounts Plan and this HRA Plan, reimbursement to the employee for his/her expenses deemed eligible under the HRA Plan, and/or eligible expenses of a covered dependent, will be provided first from any balance in the employee's Health Reimbursement Account. If the participant does not have enough funds in the HRA to provide full reimbursement for his/her eligible expenses, the remaining amount which cannot be reimbursed from the participant's HRA balance may then be submitted for reimbursement by the participant through his/her Medical Expense Reimbursement Account. An employee may not be reimbursed for the same expense from both his/her Health Reimbursement Account and the Medical Expense Reimbursement Account.


Coverage During Leave of Absence

Sabbatical or Research Leave-- A faculty member enrolled in the PPO Health Plan $1,000 with Health Reimbursement Account who takes a sabbatical or paid or unpaid research leave of absence approved through the Office of the Provost will retain his/her Health Reimbursement Account balance if the faculty member temporarily discontinues coverage through the PPO Health Plan $1,000, as permitted by the terms of that plan, during the period of sabbatical or leave of absence, providing the faculty member re-enrolls in the PPO Health Plan $1,000 immediately upon return from sabbatical or leave of absence. The faculty member's full Health Reimbursement Account balance will be restored when the faculty member re-enrolls in the PPO Health Plan $1,000, providing he/she does so as soon as eligible upon expiration of the approved sabbatical or leave of absence.

Family & Medical Leave or Other Medical Leave-- An employee enrolled in the PPO Health Plan $1,000 will not forfeit his/her Health Reimbursement Account balance if the employee temporarily discontinues health insurance coverage during an approved, unpaid leave under the Family and Medical Leave Act of 1993, as amended (FMLA), or other approved, unpaid medical leave and then re-enrolls in the PPO Health Plan $1,000 immediately upon return from leave. The employee's Health Reimbursement Account balance will be restored when he/she re-enrolls in the PPO Health Plan $1,000, providing the employee re-enrolls immediately upon return to work. If the employee is unable to return to work due to continuing disability, the individual's Health Reimbursement Account balance will be restored if the individual begins receiving long-term disability income benefits through the College's Group Long-term Disability Insurance Plan.

If a covered employee takes a qualifying leave under the Family and Medical Leave Act and the College maintains the employee's group health insurance coverage (as required by the FMLA and upon the terms and conditions described in the Group Health  & Prescription Drug Summary Plan Description), then the employee's Health Reimbursement Account balance will be available for use during the entire period that the employee remains covered under the PPO Health Plan $1,000.


Termination of Coverage

An employee's coverage under this HRA Plan will terminate when the employee's coverage under the PPO Health Plan $1,000 terminates. A spouse or dependent's coverage under this HRA Plan will terminate when the employee's spouse's or dependent's coverage under the PPO Health Plan $1,000 terminates. Eligibility for participation in the PPO Health Plan $1,000 and this Plan terminates at the end of the calendar month in which: employment termination occurs; an employee commences a leave of absence that does not provide for continued benefits coverage; and/or an employee is no longer a member of an eligible class. Please see the Shared Services Group Health Plan Summary Plan Description for detailed information (available from Human Resources, on the Human Resources web pages, and in the Human Resources public folder in eDisk).

Please see the “COBRA” section below for important information about optional, temporary continuation of coverage through the Group Health Plan following a “Qualifying Event” that leads to loss of coverage.


Health Reimbursement Account Balance Upon Termination of Participation

Upon termination of participation in the PPO Health Plan $1,000 and this HRA Plan, an employee's full Health Reimbursement Account balance will be permanently forfeited by the employee, except as described below and as required by "COBRA". 

An HRA Plan participant who elects coverage through a College health plan option other than the PPO Health Plan $1,000, and therefore terminates coverage through the PPO Health Plan $1,000, will forfeit his/her entire HRA balance. The balance will not be restored if the employee later re-enrolls in the PPO Health Plan $1,000, except as described above in the "Coverage During Leave of Absence" section of this Summary Plan Description.

Upon termination of Plan participation, an employee may request reimbursement for his/her eligible expenses, as described above in the section titled "Eligible Expenses", and those of covered dependents which were incurred during the Plan Year on or before the date participation in the PPO Health Plan $1,000 terminated.


Eligibility to Retain HRA Balance Upon Employment Termination

All amounts in each employee's Health Reimbursement Account will be forfeited upon termination of an employee's coverage under this Plan, except as required by COBRA as described below, and except that the following employees will retain their full Health Reimbursement Account balance at employment termination:

1.Faculty and professional staff who meet age and service requirements to qualify as benefits-eligible retirees of Franklin & Marshall:​

  • If age 55 or older by December 31, 2012, and employed by Franklin & Marshall in a full-time, benefits-eligible position on December 31, 2012:  Upon termination of employment, have completed at least 10 consecutive years of full-time employment after age 50 (at least age 60 upon employment termination).
  • If age 50 through 54 by December 31, 2012, and employed by Franklin & Marshall in a full-time, benefits-eligible position on December 31, 2012:  The earlier of completion of 15 continuous years of full-time employment with Franklin & Marshall after age 40 (at least age 55), or 10 consecutive years of full-time employment after age 50 (at least age 60 upon employment termination). 
  • If under age 50 as of December 31, 2012, and employed by Franklin & Marshall in a full-time, benefits-eligible position on December 31, 2012, or hired by Franklin & Marshall in a full-time, benefits-eligible position after December 31, 2012, regardless of age:  Upon termination of employment, have completed at least 15 continuous years of full-time employment with Franklin & Marshall College after age 40 (at least age 55 when employment terminates).

2.  Solely for purposes of this Health Reimbursement Account Plan, employees who terminate their College employment after completing at least 10 consecutive years of full-time employment in a benefits eligible class, and who are at least age 55 upon employment termination.

3.  Long-term disability income benefit recipients: College employees whose employment terminates and who are eligible to receive long-term disability income benefits through the Franklin & Marshall College Group Long-term Disability Plan due to total disability.

Eligible expenses for those former employees listed above will include all medical expenses qualified under Section 213(d) of the Internal Revenue Code (see IRS publication 502, http://www.irs.gov/). These former employees do not have to remain enrolled in the PPO Health Plan $1,000 or other College sponsored health plan to maintain their HRA balance. No additional funds will be deposited into the former employee's Health Reimbursement Account at the beginning of the next or subsequent Plan Years.  Funds may be used from the HRA on a tax-free basis for reimbursement of qualified medical expenses incurred by the former employee and/or his eligible tax-dependents.


 

Death of a Plan Participant

Upon the death of a current Plan participant, or a former participant who has retained his/her Health Reimbursement Account as described above, the spouse and/or eligible dependents of the individual can continue to use the funds in the HRA for reimbursement of eligible medical expenses. Eligible expenses will include all medical expenses qualified under Section 213(d) of the Internal Revenue Code (see IRS publication 502). No additional funds will be deposited at the beginning of the next or subsequent Plan Years. If there are no covered dependents at the time of the individual's death, the Health Reimbursement Account funds will be forfeited.


Re-hired Employees

An employee who terminates his/her employment for any reason, is re-hired within the same Plan Year (calendar year) in an eligible class, and re-enrolls in the PPO Health Plan $1,000 when first eligible to re-enroll during that calendar year, will have his/her Health Reimbursement Account balance restored to the balance at termination.

If an employee is re-hired during a later Plan Year (calendar year), the employee's Health Reimbursement Account balance will not be reinstated.


Plan Termination

Coverage under this Plan will terminate for all employees on the date this Plan terminates. Upon termination of this HRA Plan by the employer, all participating employees will retain their Health Reimbursement Account balances and can continue to incur eligible expenses under this Plan, but no additional funds will be credited to any Health Reimbursement Account. Eligible expenses after termination of this Plan will include only those expenses included in the section titled "Eligible Expenses". Once all remaining Health Reimbursement Account funds have been paid to employees for eligible expenses, this HRA Plan will terminate.


Benefit Denials and Claims Procedures

The procedures Plan participants are required to follow to file a complaint or grievance pertaining to denial of payment, benefits, or coverage through the Group Health Plan are available to all Plan participants and beneficiaries, at no cost. These procedures are provided with the Certificate of Insurance, which is furnished automatically to employees upon enrollment, and is also available upon request, and at no charge, from the Plan Administrator and the health insurance carrier. Plan participants must follow the procedures described in the Certificate of Insurance to appeal denial of a claim for payment or benefits under the PPO Health Plan $1,000.

The Plan Administrator shall have the responsibility and authority, in its sole discretion, to decide eligibility for coverage through this Plan. If the Administrator denies a claim for coverage through this Plan, 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.


Plan Amendment, Modification, and Termination

The Group Health Plan and the Health Reimbursement Account may be amended or terminated by Shared Services and/or Franklin & Marshall College at any time. No consent of any participant or beneficiary is required to terminate, modify, amend, or change the Plans.

Plan benefits, coverage levels, and required participant-paid contributions and other costs and Plan features are subject to change at the sole discretion of the College. Additionally, for retired employees and their dependents and COBRA participants and dependents, coverage and costs (including, but not limited to, participant-paid premiums, deductibles, coinsurance, and co-payments) are subject to change following termination of employment.


Required Notices


“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 and/or eligible dependents; and describe what an employee and his/her covered dependents must do to protect the right to elect continued health insurance coverage through COBRA, if coverage through this HRA Plan and the College's Group Health Plan is lost.

Employees of Franklin & Marshall College, and their dependents, who are covered under this HRA Plan have the right to temporary continuation of their health insurance 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 coverage is available under this Plan only if the employee, spouse, or dependent also elects COBRA coverage under the PPO Health Plan $1,000. COBRA guarantees an opportunity to elect temporary continuation of health insurance coverage at group rates. No evidence of insurability is required to choose continuation coverage. Coverage is the same as that for active employees.

Qualifying Events-- An employee of Franklin & Marshall College enrolled in this 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 under this 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 if the employee also elects continued coverage under the PPO Health Plan $1,000.

The covered spouse of a College employee 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 under this Plan for any of the following reasons:

  • the death of the College employee,
  • 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 becomes entitled to Medicare benefits (Medicare Part A, Part B or both), or  
  • the employee and his/her spouse divorce or legally separate.

A spouse 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 if the spouse also elects continued coverage under the PPO Health Plan $1,000.

The covered dependent child of a College employee has the right to elect COBRA continuation coverage, if coverage under this Plan is lost for any of the following reasons:

  • the death of the parent (employee),
  • 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) 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 this 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 this Plan, due to a Qualifying Event outlined above, becomes a "Qualified Beneficiary" entitled to elect temporary continuation of coverage through COBRA if the dependent child also elects continued coverage under the PPO Health Plan $1,000.

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, spouse, and/or dependent 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 this Plan and the College's Group Health 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 who has lost or will lose coverage under this Plan and the College's Group Health Plan, the spouse or dependent who is losing coverage, or a representative acting on behalf of the employee, spouse, or dependent. 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 or former 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 due to a Qualifying Event,
  3. a brief description of the Qualifying Event that has resulted, or will result, in loss of coverage (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 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 third party 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 reasons for the denial.

Employer Responsibility-- When the Qualifying Event is the termination of employment or reduction of hours of employment, death of the employee, 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 during the COBRA period, the employee 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 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 insurance coverage will terminate. If proper notice of a Qualifying Event is not provided, if continuation coverage through COBRA is not elected for both the PPO Health Plan $1,000 and this Plan in a timely manner, or if COBRA premiums are not paid in a timely manner by the employee/former employee or Qualified Beneficiary(ies), all coverage under this Plan 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 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. The guaranteed right to purchase an individual health insurance policy that does not impose pre-existing condition exclusions will also be forfeited. An employee/former 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.

Coverage Periods-- Continuation coverage through COBRA may be elected for a maximum period as follows:

  • If the person affected by loss of coverage 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 is an employee's spouse, and the reason for loss of coverage is the employee'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 dependent child and the reason for loss of coverage is the employee'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,

(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 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 department, 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 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-- Year 2014 monthly premiums for continued coverage through the PPO Health Plan $1,000 with HRA are as follows:

$613.92 per month for single coverage, $1,007.15 per month for the individual plus one dependent, or $1,664.63 per month for family coverage   

If the COBRA continuation period is extended for up to 29 months due to disability, 150% of the group rate is charged during the 11 month extension.

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 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 lost. 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.

The law requires that, at the end of the 18 month, 29 month, or 36 month continuation coverage period, participants be allowed to enroll in an individual conversion health plan if one is available under the terms of the College's Group Health Plan. In addition, 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. The College's health insurance carrier must be contacted directly to request conversion to an individual policy.

Questions about COBRA may be directed to Human Resources, (717) 291-3995, Ceridian Benefits Services, the College's 3rd party COBRA administrator, (800) 877-7994, Significa Benefit Services, the claims administrator for the HRA Plan, (717) 581-1300, or the U.S. Department of Labor's Employee Benefits Security Administration, www.dol.gov/ebsa.


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 this Plan for him/herself and covered dependents, at active employee rates, for up to 30 calendar days, if the employee is enrolled in the PPO Health Plan $1,000. In the case of Service leave exceeding 30 calendar days, USERRA requires the College to extend insurance 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.


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

Effective Date

This Notice is effective September 23, 2013

Our Responsibilities

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.

Special Situations

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 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:

(1) the individual identifiers have been removed; or

(2) when an institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of the requested information, and approves the research.

Required Disclosures

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.

Other Disclosures

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:

(1) you have been, or may be, subjected to domestic violence, abuse or neglect by such person; or

(2) treating such person as your personal representative could endanger you; and

(3) in the exercise of professional judgment, it is not in your best interest to treat the person as your personal representative.

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.

Your Rights

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.

Complaints

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


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 Group Health 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 Group Health 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 Plan, you should contact the Plan Administrator, via the Franklin & Marshall College Human Resources office. 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 Plan 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 and the Benefits Booklet and Summary of Vision Benefits have been complied with and exhausted.

  • To access Significa Benefit Services' website and manage your Health Reimbursement Account online, click here: www.significabenefits.com.  You can find instructions for creating an account here: Account Instructions. (To create an account on the Significa website, an F&M participant will need to enter group number 03820.)

Please also refer to Benefit Booklets, available in the Human Resources public eDisk folder and from Highmark Blue Shield, (800) 345-3806.  Benefit Booklets include detailed information about covered services, exclusions, and claims procedures.

Please click here to access the Health Care Exchange Notice: Health Care Exchange Notice

Summaries of Health Plan Options for Faculty, Staff, and Retirees:

To download summary information regarding the College's Health Plan options through Highmark, please click on the following links:

Please click here to find the "Summary of Benefits and Coverage" (SBC) for each Health Plan option:

  • PPO Health Plan $1,000 with Health Reimbursement Account: SBC
  • PPO Health Plan $300: SBC

For a quick comparison of Health Plan options, please click here: Comparison.

 

Summary of Vision Care Benefits:

For a summary of vision care benefits, please click here: NVA Vision Benefits Summary.


Health Plan Coverage for Retired Members of the College Community:

For more information about medical and prescription drug coverage for College retirees, please click here: Retiring from Franklin & Marshall

For information about the Emeriti Retirement Health Plan, applicable to faculty and professional staff who retire on or after January 1, 2013, please click here: Emeriti Plan.

You can find publications from Medicare in the Human Resources public eDisk folder ('Health & Prescription Drug Plan').


ConnectCare3 Patient Advocate Service:

Please click here to obtain information about the no-cost, confidential Patient Advocate service available to Highmark health plan participants: Connect Care3.

 

Tools:

To learn some strategies to help you manage your healthcare expenses, please click here: Controlling Your Costs.

To access Highmark's online tools for comparing the cost of facilities, providers, procedures, and prescription medicines, please click here: Highmark Web Tools.  You will need to login to the Highmark web site with your Highmark user name and ID.

To access the Signfica Benefit Services website to manage your Health Reimbursement Account (for the PPO Health Plan $1,000 only), click here: Significa.


Qualified Medical Child Support Order:

Procedures For Determining Qualified Status of a Medical Child Support Order

In accordance with Section 609(a) of the Employee Retirement Income Security Act of 1974 ("ERISA"), the Group Health Insurance & Prescription Drug Plan and the Group Dental Insurance Plan must, as required by law, observe the terms of any qualified medical child support order.

A medical child support order ("Order") is any judgment, decree, or order (including approval of a settlement agreement) issued by a court to accomplish one of two purposes. An Order may be issued pursuant to a state domestic relations law and provides for child support or health benefit coverage with respect to a child of a participant under the Group Health Insurance & Prescription Drug Plan and/or Group Dental Insurance Plan (the "Plans"), and relates to benefits under such Plans. An Order may be issued to enforce a state law relating to medical child support with respect to a group health plan.

The Plans do not have to comply with an Order unless it is "qualified". For an Order to be qualified, it must satisfy the requirements of relevant sections of ERISA. A qualified Order is one which creates or recognizes the existence of an alternate recipient's right to, or assigns to an alternate recipient the right to, receive benefits for which a participant or beneficiary is eligible under the Plans.

The following procedures have been adopted by Franklin & Marshall College ("College"), as Plan Administrator, for the purpose of determining whether an Order complies with such requirements. These procedures will be furnished, upon receipt of an Order, to the persons specified in such Order as being entitled to payments under the Plans or, upon request, to any employee covered under the Plans, eligible spouse, or any interested party who may be entitled to receive benefits under the Plans. In addition, any such person may designate a representative to receive copies of these procedures and all other pertinent correspondence related to the Order by writing to Franklin & Marshall College, Attn: Human Resources, P.O. Box 3003, Lancaster, PA  17604-3003.

Notice of Receipt

Upon receipt of an Order, the College or its authorized designee shall notify, in writing, the Participant and each child subject to the Order of receipt of the Order. This notice to the Participant and child(ren) shall acknowledge receipt of the Order and include a copy of these procedures. Any child subject to the Order may designate a representative for receipt of copies of communications sent by the Plan Administrator in connection with the Order.

Specification of Entitlement

The Order must specify that it applies to benefits under the Plans.

The Order must include the name and last known mailing address of the Participant and of each child covered by the Order.

The Order must address several issues related to the payment of benefits:

  1. The Order must provide a reasonable description of the type of coverage to be provided by the Plans to each child, or the manner in which the type of coverage is to be determined.
  2. The Order must specify the period to which the Order applies.
  3. The Order must specify each plan to which the Order applies.

Limitations

The Order will not be qualified if it provides for any type or form of benefit or any other option not otherwise available under the Plans, except to the extent it is necessary to comply with the state medical child support laws.

Interim Administration

The Plan Administrator will review any Order submitted to it and determine, in accordance with these procedures and within a reasonable period of time, whether the Order is qualified.

When the Plan Administrator determines whether an Order is qualified, it will appropriately notify all persons named in the Order, in writing, stating either that the Order is qualified or the reasons why the Order fails to be qualified. If none of such persons dispute, in writing, such determination within 60 days of such notification, such determination will be deemed to be final.

If the Order is qualified, the Plans will permit either parent to submit the appropriate enrollment forms. Each child who is required to be enrolled in the Plans as a result of a qualified medical child support order will be considered a Plan participant, and is entitled to receive a copy of the Summary Plan Description, summaries of Plan changes, and the Plan's Summary Annual Report. When a child is insured through the noncustodial parent, the Plans will provide the custodial parent information to enable the child to obtain benefits from the Plans and to permit the custodial parent to file benefit claims without the approval of the noncustodial parent. If reimbursement for health expenses paid by the child or custodial parent is required, payment will be made to the child or custodial parent.

Related Forms

Download the Health Reimbursement Account Claim Form (PDF).