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Laws Protecting Your Journey
Please read the following information to understand your rights
under Houston Methodist benefits plans. References to “Plan
Administrator” refer to the Director of Benefits at Houston
Methodist.
The following notices are included in this packet:
Health Insurance Marketplace Coverage Options and Your Health
Coverage
............................................................ 2
HIPAA Notice of Special Enrollment Rights
.....................................................................................................................
3
Health Insurance Portability and Accountability Act of 1996
(HIPAA) Notice of Privacy Practices ..............................
4
Notice of Privacy Practices for the Comprehensive Welfare
Benefits Plan of Houston Methodist .............................
5
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
............................................................................
8
Prescription Drug Coverage and Medicare (Medicare Part D)
....................................................................................
12
Women’s Health and Cancer Rights Act
.......................................................................................................................
14
The Newborns’ and Mothers’ Health Protection Act Notice
........................................................................................
14
Mental Health Parity and Addiction Equity Notice
.......................................................................................................
14
Right to Designate a Primary Care Provider Notice
.....................................................................................................
15
Summary of Benefits and Coverage Available
.............................................................................................................
15
Workers’ Compensation
................................................................................................................................................
15
Qualified Medical Child Support Order (QMCSO)
.........................................................................................................
16
Premium Assistance under Medicaid and the Children’s Health
Insurance Program (CHIP) ................................... 16
Your Rights Under the Family Medical Leave Act of 1993 (FMLA)
.............................................................................
18
The Employee Retirement Income Security Act of 1974 (ERISA)
...............................................................................
21
Uniformed Services Employment and Reemployment Rights Act of
1994 (USERRA) ........................................... ...
20
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Health Insurance Marketplace Coverage Options and Your Health
Coverage Key parts of the Affordable Care Act, also known as the
health care reform law, went into effect on January 1, 2014,
offering a new way to buy health insurance: the Health Insurance
Marketplace (the “Marketplace,” also sometimes called the
“exchange”). To assist you as you evaluate options for you and your
family, this notice provides basic information about the new
Marketplace and employment-based health coverage offered by Houston
Methodist.
We’ve made sure that the health coverage available through
Houston Methodist provides you with comprehensive, affordable
coverage. However, U.S. employers are required to send this notice
to employees to raise awareness of the new Marketplace and to help
them understand how having access to their employer’s health care
plan may limit their eligibility for federal subsidies in the
Marketplace.
What Is the Health Insurance Marketplace? The Marketplace is
designed to help individuals find health insurance that meets their
needs and fits their budget. It offers “one-stop shopping” to find
and compare private health insurance options. Individuals may also
be eligible for a new kind of tax credit that lowers their monthly
premium right away. All U.S. citizens and legal residents will have
access to individual health insurance policies through the
Marketplace in their state. Open enrollment for health insurance
coverage through the Marketplace begins in November 1, 2016 for
coverage starting January 1, 2017. Can I Save Money on Health
Insurance Premiums in the Marketplace? Some people who do not have
access to affordable, minimum-value health care coverage through
their employer may be eligible for federal subsidies in order to
make buying insurance through the Marketplace more affordable.
Eligibility for these federal subsidies depends on household
income. Please note that the Houston Methodist health care plan
options meet the government’s standards for minimum value and
affordability. Does Employer Health Coverage Affect Eligibility for
Federal Subsidies through the Marketplace? Yes. If you have health
coverage available through Houston Methodist, you are likely not
eligible for federal subsidies through the Marketplace. You may be
eligible for a tax credit that lowers your monthly premiums or a
reduction in certain cost-sharing if the cost of the lowest cost
“Employee-only” Houston Methodist Medical Plan option —see the 2017
Rates for the Choice Plan Option on myHR.HoustonMethodist.org — is
more than 9.69% of your annual household income for the 2017 tax
year*. What If I’m Not Eligible for the Houston Methodist Medical
Plan? If you are not eligible for the Houston Methodist Medical
Plan, you should consider other options available to you, such as
coverage through your spouse’s employer plan, your parent’s
employer plan (if you are under age 26), Medicaid, Medicare or your
state’s Marketplace. Enrollment in the Marketplace begins in
November 2016. If you have questions about your Houston Methodist
benefits, visit myHR.HoustonMethodist.org or contact HR Benefits at
832.667.6211 or [email protected].
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If you decide to enroll through the Marketplace, you will need
to provide the Marketplace with the following information about
Houston Methodist and our health care plans: Employer name: Houston
Methodist Employer Identification Number EIN: 74-1180155 Employer
address: 6565 Fannin, GB 164, Houston, Texas 77030 Employer
telephone number: 832.667.6211 Name of contact for employee health
coverage: HR Benefits at 832.667.6211 Phone number of contact (if
different from above): 832.667.6211 Email address of contact:
[email protected]
Important Note: If you purchase a medical plan through the
Marketplace instead of accepting health coverage offered by Houston
Methodist, then you may lose Houston Methodist’s contribution to
the company-offered coverage. Also, this contribution — as well as
your employee contribution to employer-offered coverage — is often
excluded from income for federal and state income tax purposes.
Your payments for coverage through the Marketplace are made on an
after-tax basis.
How Can I Get More Information? If you’d like to learn more
about the Health Insurance Marketplace in your state, please visit
www.healthcare.gov, the website sponsored by the Department of
Health and Human Services, for more information. The Marketplace
can help you evaluate your coverage options, including your
eligibility for coverage through the Marketplace and its cost. If
you decide to shop for coverage in the Marketplace,
www.healthcare.gov will guide you through the process. * An
employer-sponsored health plan meets the "minimum value standard"
if the plan's share of the total allowed benefit costs covered by
the plan is no less than 60 percent of such costs..
HIPAA Notice of Special Enrollment Rights THIS NOTICE DESCRIBES
SPECIAL CIRCUMSTANCES WHICH MAY ALLOW YOU AND YOUR ELIGIBLE
DEPENDENTS TO ENROLL IN HOUSTON METHODIST GROUP HEALTH COVERAGE
DURING THE YEAR. PLEASE REVIEW IT CAREFULLY.
Houston Methodist sponsors a group health plan (the “Plan”) to
provide coverage for health care services for our employees and
their eligible dependents. Our records show that you are eligible
to participate, which requires that you complete enrollment in the
Plan and pay your portion of the cost of coverage through payroll
deductions or decline coverage. A federal law called HIPAA requires
we notify you about your right to later enroll yourself and
eligible dependents for coverage in the Plan under “special
enrollment provisions” described below.
Special Enrollment Provisions Loss of Other Coverage. If you
decline enrollment for yourself or for an eligible dependent
because you had other group health plan coverage or other health
insurance, you may be able to enroll yourself and your dependents
in the Plan if you or your dependents lose eligibility for that
other coverage, or if the other employer stops contributing toward
your or your dependents’ other coverage. You must request
enrollment within 60 days after you or your dependents’ other
coverage ends, or after the other employer stops contributing
toward the other coverage. Please contact Houston Methodist HR
Benefits at 832.667.6211 or [email protected] for
details, including the effective date of coverage added under this
special enrollment provision (contact information provided
below).
New Dependent by Marriage, Birth, Adoption, or Placement for
Adoption. If you gain a new dependent as a result of a marriage,
birth, adoption, or placement for adoption, you may be able to
enroll yourself and your new dependents in the Plan. You must
request enrollment within 60 days after the marriage, birth,
adoption, or placement for adoption. In the event you acquire a new
dependent by birth, adoption, or placement for adoption, you may
also be able to enroll your spouse in the Plan, if your spouse was
not previously covered. Please contact
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Houston Methodist HR Benefits at 832.667.6211 or
[email protected] for details, including the
effective date of coverage added under this special enrollment
provision (contact information provided below).
Enrollment Due to Medicaid/CHIP Events. If you or your eligible
dependents are not already enrolled in the Plan, you may be able to
enroll yourself and your eligible dependents in the Plan if: (i)
you or your dependents lose coverage under a state Medicaid or
children’s health insurance program (CHIP), or (ii) you or your
dependents become eligible for premium assistance under state
Medicaid or CHIP. You must request enrollment within 60 days from
the date of the Medicaid/CHIP event. Please contact Houston
Methodist HR Benefits at 832.667.6211 or
[email protected] for details, including the
effective date of coverage added under this special enrollment
provision (contact information provided below).
Contact Information If you have any questions about this Notice
or about how to enroll in the Plan, please contact Houston
Methodist HR Benefits at 832.667.6211 or
[email protected] or by writing to:
Houston Methodist Houston Methodist HR Benefits 6565 Fannin, GB
164 Houston, TX 77030
Notice Availability A copy of this notice is available at our
website, myHR.HoustonMethodist.org. Additional information
regarding your rights to enroll in the Plan are found in the
applicable summary plan description(s) for the Plan, or you may
contact Houston Methodist HR Benefits at 832.667.6211 or
[email protected] as provided above for more
information.
Health Insurance Portability and Accountability Act of 1996
(HIPAA) Notice of Privacy Practices Under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), Houston
Methodist health care plans (the ”Plan”) are required to provide
you with a HIPAA Notice of Privacy Practices (“Notice”) at the time
of your enrollment and at certain other times. In addition, the
Plan is required to periodically notify you of the availability of
the Notice and provide you with information on how to obtain a copy
of the Notice.
You may obtain a copy of the Plan’s Notice at any time by
accessing myHR.HoustonMethodist.org. To request a paper copy of
this notice, contact HR Benefits at 832.667.6211 or
[email protected], Monday – Friday, 7:30 a.m. – 5
p.m. To the extent that the Plan contains benefits other than those
covered under HIPAA’s privacy rules, this reminder pertains only to
those health care benefits that are covered under HIPAA’s privacy
rules.
Note: If you are covered by one or more fully-insured group
health plans offered by Houston Methodist, you will receive a
separate note regarding the availability of the Notice and how to
obtain a copy of the Notice directly from the insurance
carrier(s).
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Notice of Privacy Practices for the Comprehensive Welfare
Benefits Plan of Houston Methodist This notice, effective October
2016, describes how 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 identifies the general ways
your protected health information can be used or disclosed.
Protected health information is the individually identifiable
personal health information found in your medical and billing
records. This information is created or received by a health care
provider, insurance company, or employer, and relates to your past,
present, or future physical or mental health conditions. This
information can be transmitted or maintained in any form by Houston
Methodist.
As used in this notice, the term “Plan” refers to the
Comprehensive Welfare Benefits Plan of Houston Methodist, the term
“Participant” refers to an individual who is a Participant in the
Plan and thereby entitled to health benefits under the Plan and the
term “Potential Participant” refers to an individual who may at
some time become a Participant but who is not yet a Participant. If
you have any questions about this notice, please contact the
Privacy Officer of the Plan.
This notice describes your legal rights regarding your health
information. It also informs you of the legal duties and privacy
practices of Houston Methodist and its Plan with respect to your
health information created by virtue of your participation in the
Plan.
Our Legal Duties We are required, by law, to keep your
identifiable health information private; provide you with this
Notice of our legal duties and privacy practices with respect to
your health information; and follow the terms of the Notice as long
as it is in effect. If we revise this Notice, we will follow the
terms of the revised Notice, as long as it is in effect.
How We May Use and Disclose Your Health Information The
following information describes how we are permitted, or required
by law, to use and disclose your health information. Not every use
or disclosure in a category will be listed.
Treatment — The Plan may receive, use and disclose health
information about you to help you obtain health treatment or
services. For example, the Plan may request and receive from a
doctor who is treating you information about the health condition
for which you are seeking treatment in order to determine if the
treatment you are seeking (for instance, cosmetic surgery) is or is
not covered by the Plan.
Payment — The Plan may receive, use and disclose health
information about you so that the bills for health treatment and
services you have received may be paid by the Plan. For example,
the Plan may need to be provided with information about a surgery
you received, in order to determine if the charges exceed the
reasonable and customary charges for such surgery and to determine
what portion of the bill submitted for the surgery should be paid
by the Plan. The Plan might also need to receive information about
a health condition you have, in advance of a procedure for that
condition, when pre-procedure approval is required in order to
qualify for any Plan payment for the procedure or for Plan payment
at a more favorable reimbursement rate for the procedure. The Plan
may receive use and disclose health information to fiduciaries of
the Plan in order to provide them with information necessary to
process and determine any claims you may make for Plan benefits or
appeals that you may make of claims for Plan benefits, which have
been denied. The Plan may also use and disclose health information
to coordinate with other health plans to determine coverage
benefits for your claim.
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For Health Care Operations — The Plan may receive, use and
disclose health information about you for purposes of underwriting,
premium rating or other activities relating to the creation,
renewal or replacement of a contract of health insurance or health
benefits. For instance, the Plan may request from any insurer
currently funding or providing benefits under the Plan, information
relating to your and other Plan Participants’ health procedures and
treatments over a prior period, in order to provide other insurers
with information to make knowledgeable bids to ensure Plan benefits
for future periods. The Plan is prohibited from using or disclosing
health information that is genetic information about an individual
for underwriting purposes.
Health and Wellness Information — We may use your PHI to contact
you with information about: treatment alternatives; therapies;
health care providers; settings of care; or other health-related
benefits, services and products that may be of interest to you. For
example, we might send you information about tobacco/nicotine
cessation programs.
Plan Sponsor Information Request — The Plan may disclose to
Houston Methodist, (the Plan Sponsor) at their request, any summary
health information (i.e., information that summarizes the claims
history, claims expenses or type of claims experienced by covered
persons under the Plan) for the purpose of obtaining premium bids
for providing health insurance coverage under the Plan or
modifying, amending or terminating the Plan. For example, the Plan
Sponsor may request summary health information about Plan
Participants’ claims over a given period to determine ways in which
the Plan might be amended in the future to reduce costs of
providing the Plan. The following is an alphabetical listing of the
other types of uses and disclosures of health information that may
be made by the Plan:
As Required by Law — The Plan will use or disclose health
information about you when required by Federal, state, or local
law.
Business Associates — Houston Methodist may contract with an
entity to perform services on behalf of the Plan. The Plan may then
disclose your health care information to such “Business Associate.”
The Business Associate will use or disclose your health information
only to the extent the Plan would be able to do so, under the terms
of this Section.
Health-related Benefits and Services — The Plan may contact you
to give you information about health-related benefits and services
that may interest you.
Individuals Involved in Your Care or Payment for Your Care — The
Plan may use or disclose your health information to notify a
relative, personal representative, or other person responsible for
your care, about your location and general condition. The Plan will
also disclose your health information to your relative, close
personal friend, or any other person you identify, if the
information relates to that person’s involvement with your health
care or payment for your health care.
Public Health and Safety — We may use or disclose health
information, as authorized or required by local, State or Federal
law, for the following purposes deemed to be in the public interest
or benefit:
To report certain diseases and wounds, births and deaths, and
suspected cases of abuse, neglect, or domestic violence
To help identify, locate, or report criminal suspects, crime
victims, suspicious deaths, or criminal conduct on Houston
Methodist’s premises
To respond to a court order, subpoena, or other judicial process
To assist Federal disaster relief efforts To enable product
recalls, repairs, or replacements To respond to an audit,
inspection, or investigation by a health-related government agency
To assist in Federal intelligence, counterintelligence, and
national security issues To facilitate organ and tissue donations
To assist coroners, medical examiners, and funeral directors
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To respond to a request from a jail or prison regarding an
inmate’s health or medical treatment To respond to a request from
your military command authority (if you are a member or veteran of
the
armed forces) To provide information to a workers’ compensation
program
Research — The Plan will disclose information to researchers in
preparation for a research study or after the research has been
approved by an Institutional Review Board or Privacy Board. These
Boards review the research proposal and establish protocols to
ensure the privacy of your health information.
Secretary of Health and Human Services — As required by law, the
Plan will disclose health information to the Secretary of Health
and Human Services, a Federal agency that investigates compliance
with Federal privacy law.
Serious Threat to Health and Safety — The Plan may use or
disclose your health information if necessary because of a serious
threat to someone’s health or safety.
Workers Compensation — The Plan will disclose health information
to the extent authorized by and to the extent necessary to comply
with laws relating to workers compensation or similar programs
providing benefits for work-related injuries or illnesses.
Your Health Information Rights You have the following rights,
with certain exceptions, regarding your health information that is
maintained by the Plan.
Authorizations — Other uses or disclosures of your health
information not described above, including the use and disclosure
of psychotherapy notes and the use or disclosure of health
information for fundraising or marketing purposes, will not be made
without your written authorization. You may revoke written
authorization at any time, so long as your 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. You may elect to opt out of receiving
fundraising communications from us at any time.
Confidential Communications — You have the right to request that
we communicate health information to you by an alternate means or
location other than your home address and telephone number. Your
request must be made in writing to the Plan’s contact person, and
must specify how or where you wish to be contacted. We will try to
accommodate your request for alternate communications. If you
request an alternate means of communication, that request also
should be communicated by you to all of your physicians, including
your private physician.
Restrictions — You have the right to request that we restrict
the use or disclosure of your health information for treatment,
payment, or health care operations. While we are not required to
agree to your request, if we do agree, your request will be
complied with, unless the information is needed to provide
emergency treatment to you. Your request must be made in writing to
our listed contact person.
Access — You have the right to review and obtain a copy of your
health information, with certain exceptions. Usually, this includes
medical and billing records, but does not include psychotherapy
notes. Your request to review or obtain a copy of your health
information must be in writing to our listed contact person. You
will be charged fees for processing, copying, and postage as
authorized by Texas State law.
You have the right to a paper copy of this Notice. In addition,
a copy of this Notice also may be obtained at our website,
myHR.HoustonMethodist.org.
Also, if you have any questions or need information regarding
our legal duties and privacy practices, or how to exercise any of
your health information rights listed in this Notice, please
contact:
Business Practices Officer Houston Methodist 1130 Earle Street,
AX200 Houston, Texas 77030 713.383.5177
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Amendment — If you feel that the health information we have
about you is incorrect or incomplete, you have the right to ask for
an amendment of that information. You have the right to request an
amendment for as long as the information is kept by or for us. Your
request for an amendment must be made in writing to our listed
contact person, and include a reason that supports your
request.
Accounting of Disclosures — You have the right to request a list
of disclosures that we have made of your health information, except
for disclosures made for treatment, payment or health care
operations, those authorized by you, and certain other disclosures.
Your request must be in writing to our listed contact person, and
must state a time period for which you want an accounting. The time
period may not be longer than six years, and may not include dates
before April 14, 2003. The first accounting you request within a
twelve-month period will be free. A fee will be charged for
additional lists within this same time period.
Breach Notification — In certain instances, you have the right
to be notified in the event that we, or one of our Business
Associates, discover an inappropriate use or disclosure of your
health information. Notice of any such use or disclosure will be
made in accordance with state and federal requirements.
Revisions of this Notice — We reserve the right to change this
Notice, and the right to make the new provisions effective for all
health information we currently maintain, as well as any
information we receive in the future. If we make a major change to
this Notice, the revised Notice will be posted and on our website.
In addition, a paper copy of the revised Notice will be available
upon request.
To Report a Complaint — If you believe your health information
privacy rights have been violated, you can file a complaint with us
or with the Secretary of the United States Department of Health and
Human Services. There will not be any penalty or retaliation
against you for making a complaint to us or to the Department of
Health and Human Services.
Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA)
Continuation of Coverage If you lose coverage, you may have the
right to extend it under the Consolidated Budget Reconciliation Act
of 1985 (COBRA). Continuation coverage under COBRA is available
only to benefit plans that are subject to the terms of COBRA. At
Houston Methodist, the medical plans, vision plan, dental plans,
employee assistance program (EAP), and health care flexible
spending account are subject to the provisions of COBRA.
You may have other options available to you when you lose group
health coverage. For example, you may be eligible to buy an
individual plan through the Health Insurance Marketplace. By
enrolling in coverage through the Marketplace, you may qualify for
lower costs on your monthly premiums and lower out-of-pocket costs.
Additionally, you may qualify for a 30-day special enrollment
period for another group health plan for which you are eligible
(such as a spouse’s plan), even if that plan generally doesn’t
accept late enrollees. Are there other coverage options besides
COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA
continuation coverage, there may be other coverage options for you
and your family through the Health Insurance Marketplace, Medicaid,
or other group health plan coverage options (such as a spouse’s
plan) through what is called a “special enrollment period.” Some of
these options may cost less than COBRA continuation coverage. You
can learn more about many of these options at
www.healthcare.gov.
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Continuation Coverage under Federal Law (COBRA) Much of the
language in this section comes from the Federal law that governs
continuation coverage. You should call your Plan Administrator if
you have questions about your right to continue coverage.
In order to be eligible for continuation coverage under Federal
law, you must meet the definition of a “Qualified Beneficiary”. A
Qualified Beneficiary is any of the following persons who were
covered under the Plan on the day before a qualifying event:
A Participant; A Participant’s enrolled dependent, including
with respect to the
Participant’s children, a child born to or placed for adoption
with the Participant during a period of continuation coverage under
Federal law; or
A Participant’s former spouse.
Qualifying Events for Continuation Coverage under COBRA The
table on the following page outlines situations in which you may
elect to continue coverage under COBRA for yourself and your
dependents, and the maximum length of time you can receive
continued coverage. These situations are considered qualifying
events.
If Coverage Ends Because of the Following Qualifying Events:
You may Elect COBRA: For Yourself
For Your Spouse For Your Child(ren)
Your work hours are reduced 18 months 18 months 18 months Your
employment terminates for any reason (other than gross
misconduct)
18 months 18 months 18 months
You or your family member become eligible for Social Security
disability benefits at any time within the first 60 days of losing
coverage1
29 months 29 months 29 months
You die N/A 36 months3 36 months3 You divorce (or legally
separate) N/A 36 months 36 months Your child is no longer an
eligible family member (e.g., reaches the maximum age limit)
N/A N/A 36 months
You become entitled to Medicare N/A See Medicare table
See Medicare table
The Plan Sponsor files for bankruptcy under Title 11, United
States Code2
N/A 36 months 36 months
1. Subject to the following conditions: (i) notice of the
disability must be provided within the latest of 60 days after a)
the determination of the disability, b) the date of the qualifying
event, c) the date the Qualified Beneficiary would lose coverage
under the Plan, and in no event later than the end of the first 18
months; (ii) the Qualified Beneficiary must agree to pay any
increase in the required premium for the additional 11 months over
the original 18 months; and (iii) if the Qualified Beneficiary
entitled to the 11 months of coverage has non-disabled family
members who are also Qualified Beneficiaries, then those
non-disabled Qualified Beneficiaries are also entitled to the
additional 11 months of continuation coverage. Notice of any final
determination that the Qualified Beneficiary is no longer disabled
must be provided within 30 days of such determination. Thereafter,
continuation coverage may be terminated on the first day of the
month that begins more than 30 days after the date of that
determination.
2. This is a qualifying event for any retired Participant and
his or her enrolled Dependents if there is a substantial
elimination of coverage within one year before or after the date
the bankruptcy was filed.
3. From the date of the Participant’s death if the Participant
dies during the continuation coverage.
If you or your Dependents fail to notify the Plan Administrator
of a Qualifying COBRA Event within 60 days, the Plan Administrator
is not obligated to provide continued coverage to the affected
Qualified Beneficiary. If you are continuing coverage under COBRA,
you must notify the Plan Administrator within 60 days of the birth
or adoption of a child.
You will have up to 60 days from the date you receive
notification or 60 days from the date your coverage ends to elect
COBRA coverage, whichever is later. You will then have an
additional 45 days to pay the cost of your COBRA coverage,
retroactive to the date your Plan coverage ended.
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How Your Medicare Eligibility Affects Dependent COBRA Coverage
The table below outlines how your Dependents’ COBRA coverage is
impacted if you become entitled to Medicare.
If Dependent Coverage Ends When: You May Elect COBRA Dependent
Coverage For Up To:
You become entitled to Medicare and don’t experience any
additional qualifying events 18 months You become entitled to
Medicare, after which you experience a second qualifying event*
before the initial 18-month period expires
36 months
You experience a qualifying event*, after which you become
entitled to Medicare before the initial 18-month period expires;
and, if absent this initial qualifying event, your Medicare
entitlement would have resulted in loss of Dependent coverage under
the Plan
36 months
* Your work hours are reduced or your employment is terminated
for reasons other than gross misconduct.
Trade Act of 2002 The Trade Act of 2002 amended COBRA to provide
for a special second 60-day COBRA election period for certain
Participants who have experienced a termination or reduction of
hours and who lose group health plan coverage as a result. The
special second COBRA election period is available only to a very
limited group of individuals: generally, those who are receiving
trade adjustment assistance (TAA) or “alternative trade adjustment
assistance” under a Federal law called the Trade Act of 1974. These
Participants are entitled to a second opportunity to elect COBRA
coverage for themselves and certain family members (if they did not
already elect COBRA coverage), but only within a limited period of
60 days from the first day of the month when an individual begins
receiving TAA (or would be eligible to receive TAA but for the
requirement that unemployment benefits be exhausted) and only
during the six months immediately after their group health plan
coverage ended.
If a Participant qualifies or may qualify for assistance under
the Trade Act of 1974, he or she should contact the Plan
Administrator for additional information. The Participant must
contact the Plan Administrator promptly after qualifying for
assistance under the Trade Act of 1974 or the Participant will lose
his or her special COBRA rights. COBRA coverage elected during the
special second election period is not retroactive to the date that
Plan coverage was lost, but begins on the first day of the special
second election period.
Getting Started You will be notified by mail if you become
eligible for COBRA coverage as a result of a reduction in work
hours or termination of employment. The notification will give you
instructions for electing COBRA coverage, and advise you of the
monthly cost. Your monthly cost is the full cost, including both
Participant and Employer Costs, plus a 2% administrative fee or
other cost as permitted by law.
During the 60-day election period, the Plan will, only in
response to a request from a Provider, inform that Provider of your
right to elect COBRA coverage, retroactive to the date your COBRA
eligibility began.
Notification Requirements If your covered dependents lose
coverage due to divorce, legal separation, or loss of dependent
status, you or your dependents must notify the Plan Administrator
within 60 days of the latest of:
The date of the divorce, legal separation or an enrolled
dependent’s loss of eligibility as an enrolled dependent;
The date your enrolled dependent would lose coverage under the
Plan; or The date on which you or your enrolled dependent are
informed of your obligation to provide notice and the
procedures for providing such notice.
While you are a participant in the medical, vision, and/or
dental plan under COBRA, you have the right to change your coverage
election:
During Open Enrollment; and Following a change in family
status.
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You or your dependents must also notify the Plan Administrator
when a qualifying event occurs that will extend continuation
coverage. Once you have notified the Plan Administrator, you will
then be notified by mail of your election rights under COBRA.
Notification Requirements for Disability Determination If you
extend your COBRA coverage beyond 18 months because you are
eligible for disability benefits from social security, you must
provide WageWorks (Houston Methodist’s COBRA vendor) with notice of
the social security administration’s determination within 60 days
after you receive that determination, and before the end of your
initial 18-month continuation period.
For events other than disability, the notice requirements will
be satisfied by providing written notice to the Plan Administrator
at 6565 Fannin, GB 164, Houston, Texas, 77030. For disability,
written notice must be provided to WageWorks. For more information,
please contact WageWorks by calling 877.502.6272. The contents of
the notice must be such that the Plan Administrator is able to
determine the covered Participant and qualified beneficiary(ies),
the qualifying event or disability, and the date on which the
qualifying event occurred.
None of the notice requirements will be enforced if the
participant or dependent is not informed of his or her obligations
to provide such notice.
When COBRA Ends COBRA coverage will end before the maximum
continuation period shown previously if:
You or your covered dependent becomes covered under another
group medical plan, as long as the other plan doesn’t limit your
coverage due to a pre-existing condition; or if the other plan does
exclude coverage due to your pre-existing condition, your COBRA
benefits would end when the exclusion period ends. The other group
health coverage will be primary for all health services except
those health services that are subject to the pre-existing
condition limitation or exclusion.
You or your covered dependent becomes eligible for Medicare
after electing COBRA; The first required premium is not paid within
45 days; Any other monthly premium is not paid within 31 days of
its due date; The entire Plan ends; or Coverage would otherwise
terminate under the Plan as described in the beginning of this
section.
NOTE: If you selected continuation coverage under a prior plan
which was then replaced by coverage under this Plan, continuation
coverage will end as scheduled under the prior plan or in
accordance with the terminating events listed in this section,
whichever is earlier.
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Prescription Drug Coverage and Medicare (Medicare Part D)
Important Notice from Houston Methodist About Your Prescription
Drug Coverage and Medicare Please read this notice carefully and
keep it where you can find it. This notice has information about
your current prescription drug coverage with Houston Methodist and
about your options under Medicare’s prescription drug coverage.
This information can help you decide whether or not you want to
join a Medicare drug plan. If you are considering joining, 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.
Information about where you can get help to make decisions about
your prescription drug coverage is at the end of this notice.
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. 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. Houston Methodist has determined that the prescription drug
coverage offered by the Houston Methodist Employee Medical Plan is,
on average for all plan participants, expected to pay out as much
as standard Medicare prescription drug coverage pays and is
therefore considered Creditable Coverage. Because your existing
coverage is Creditable Coverage, you can keep this coverage and not
pay a higher premium (a penalty) if you later decide to join a
Medicare drug plan.
When Can You Join a Medicare Drug Plan? You can join a Medicare
drug plan when you first become eligible for Medicare and each year
from October 15 to December 7.
However, if you lose your current creditable prescription drug
coverage, through no fault of your own, you will also be eligible
for a two-month Special Enrollment Period (SEP) to join a Medicare
drug plan.
What Happens to Your Current Coverage if You Decide to Join a
Medicare Drug Plan? If you decide to join a Medicare drug plan,
your current Houston Methodist coverage will not be affected. If
you do decide to enroll in a Medicare prescription drug plan and
drop your Houston Methodist prescription drug coverage, be aware
that you may not be able to get this coverage back.
If you drop your coverage with Houston Methodist and enroll in a
Medicare prescription drug plan, you may not be able to get this
coverage back later. If you remain an active employee or on a leave
of absence, you will be able to re-enroll in the medical plan that
includes your current prescription drug benefit at open enrollment.
However, if you are continuing coverage through COBRA, you will not
be able to re-enroll once you cancel your current Houston Methodist
coverage.
You should compare your current coverage, including which drugs
are covered, with the coverage and cost of the plans offering
Medicare prescription drug coverage in your area. Under your
current medical plan, after you pay an annual pharmacy deductible
of $50, you may purchase a one-month supply (up to 30 days) of a
generic drug at your local pharmacy for a $10 co-pay, preferred
brand name drug for 30% coinsurance (Min $35 – Max $75), and
non-preferred brand name drug for 50% coinsurance (Min $50 – Max
$125). You may also purchase a 90-day supply of a maintenance
prescription drug through mail order for a $25 co-pay for a generic
drug, 30%
Remember:
Keep this Creditable Coverage notice. If you decide to join one
of the Medicare drug plans, you may be required to provide a copy
of this notice when you join to show whether or not you have
maintained creditable coverage and, therefore, whether or not you
are required to pay a higher premium (a penalty).
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13
coinsurance (Min $90 – Max $190) for a preferred brand name
drug, and 50% coinsurance (Min $125 – Max $315) for a non-preferred
brand-name drug.
In addition, your current coverage pays for other health
expenses, in addition to prescription drugs, and you may or may not
be eligible to receive all of your current health and prescription
drug benefits if you choose to enroll in a Medicare prescription
drug plan:
If you are currently enrolled in a Houston Methodist medical
plan as a COBRA participant but are not currently a Medicare
participant and become enrolled in Medicare and a Medicare
prescription drug program, you will not be able to continue your
current Houston Methodist health and prescription drug
benefits.
If you are currently enrolled in a Houston Methodist medical
plan as a COBRA participant and you are also enrolled in Medicare
and you choose to enroll in a Medicare prescription drug plan, you
will be able to continue your current Houston Methodist health and
prescription drug benefits.
If you are an active employee on a leave of absence and either
you are enrolled or become enrolled in Medicare, and you choose to
enroll in a Medicare prescription drug plan, you will be able to
continue coverage under your Houston Methodist health and
prescription drug benefits.
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 with Houston Methodist and don’t 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 creditable
prescription drug coverage, your monthly premium may go up by 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 nineteen months without creditable coverage, your premium
may consistently be at least 19% higher than the Medicare base
beneficiary premium. You may have to pay this higher premium (a
penalty) as long as you have Medicare prescription drug coverage.
In addition, you may have to wait until the following October to
join.
For More Information about This Notice or Your Current
Prescription Drug Coverage… Contact the person listed below for
further information or contact HR Benefits at 832.667.6211 or
[email protected]. NOTE: You’ll get this notice each
year. You will also get it before the next period you can join a
Medicare drug plan, and if this coverage through Houston Methodist
changes. You also may request a copy of this notice at any
time.
Date: 10/01/2016 Name of Entity/Sender: Houston Methodist /
Virginia “Libby’ Apostol Contact/Position/Office: Manager, Benefits
Administration Address: 6565 Fannin, GB164, Houston, Texas 77030
Phone Number: 832.667.6220
For More Information About Your Options Under Medicare
Prescription Drug Coverage… More detailed information about
Medicare plans that offer prescription drug coverage is in the
“Medicare & You” handbook. You’ll get a copy of the handbook in
the mail every year from Medicare. You may also be contacted
directly by Medicare drug plans.
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14
For more information about Medicare prescription drug
coverage:
Visit www.medicare.gov Call your State Health Insurance
Assistance Program (see the inside back cover of your copy of the
“Medicare
& You” handbook for their telephone number) for personalized
help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call
1-877-486-2048.
If you have limited income and resources, extra help paying for
Medicare prescription drug coverage is available. For information
about this extra help, visit Social Security on the web at
www.socialsecurity.gov or call them at 1-800-772-1213 (TTY
1-800-325-0778).
Women’s Health and Cancer Rights Act The Women’s Health and
Cancer Rights Act (WHCRA), signed into law on October 21, 1998,
protects patients who elect breast reconstruction due to a
mastectomy. Health care plans must cover reconstructive surgery
following a mastectomy, as determined in consultation with the
attending physician and the patient.
Under WHCRA, mastectomy benefits must include coverage for:
All stages of reconstruction of the breast on which the
mastectomy was performed Surgery and reconstruction of the other
breast to produce a symmetrical appearance Prostheses and treatment
of physical complications at all stages of mastectomy, including
lymphedemas
These benefits are subject to the Houston Methodist Medical
Plan’s regular annual deductibles and coinsurance. Questions about
this law or mastectomy related benefits covered under the medical
plans of Houston Methodist should be directed to your HR department
or HR Benefits at 832.667.6211 or
[email protected].
The Newborns’ and Mothers’ Health Protection Act Notice Group
health plans and health insurance issuers generally may not, under
federal law, restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child to less
than 48 hours following a vaginal delivery, or less than 96 hours
following a cesarean section. However, federal law generally does
not prohibit the mother's or newborn's attending provider, after
consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours as applicable). In any
case, plans and issuers may not, under federal law, require that a
provider obtain authorization from the plan or the issuer for
prescribing a length of stay not in excess of 48 hours (or 96
hours).
Mental Health Parity and Addiction Equity Notice Houston
Methodist’s group medical plans provide and administer mental
health and substance abuse benefits as required by the Mental
Health Parity and Addiction Equity Act of 2008 (“MHPAEA”). For more
information about Houston Methodist’s group medical plans and their
compliance under the MHPAEA, please contact the HR Benefits at
832.667.6211 or [email protected].
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Right to Designate a Primary Care Provider Notice Houston
Methodist allows, but does not require, the designation of a
primary care provider. You have the right to designate any primary
care provider who participates in the UnitedHealthcare network and
who is available to accept you or your family members. For
information on how to select a primary care provider, and for a
list of the participating primary care providers, contact
UnitedHealthcare at the number listed on the back of your member ID
card or online at www.uhc.com. For children, you may designate a
pediatrician as the primary care provider.
Summary of Benefits and Coverage Available As an employee, the
health benefits available to you represent a significant component
of your compensation package. They also provide important
protection for you and your family in the case of illness or
injury. Your plan offers a series of health coverage options.
Choosing a health coverage option is an important decision. To help
you make an informed choice, your plan makes available a Summary of
Benefits and Coverage (SBC), which summarizes important information
about any health coverage option in a standard format, to help you
compare across options.
The SBC is available on the web at myHR.HoustonMethodist.org. A
paper copy is also available, free of charge, by contacting Houston
Methodist HR Benefits at 832.667.6211 or at
[email protected].
Workers’ Compensation COVERAGE: Houston Methodist has workers’
compensation insurance coverage from Zurich Insurance Company to
protect you in the event of a work-related injury or illness. This
coverage is effective from May 1, 2009. Any injuries or illnesses,
which occur on or after that date, will be handled by Zurich Claims
Service. An employee or a person acting on the employee’s behalf,
must notify the employer of an injury or occupational disease not
later than the 30th day after the date on which the injury occurs
or the date the employee knew or should have known of an
occupational disease, unless the Texas Department of Insurance,
Division of Workers’ Compensation (Division) determines that good
cause existed for failure to provide timely notice. Your employer
is required to provide you with coverage information, in writing,
when you are hired or whenever the employer becomes, or ceases to
be, covered by workers’ compensation insurance.
You may elect to retain your common law right of action if, no
later than five days after you begin employment or within five days
after receiving written notice from the employer that the employer
has obtained workers’ compensation insurance coverage, you notify
your employer in writing that you wish to retain your common law
right to recover damages for personal injury. If you elect to
retain your common law right of action, you cannot obtain workers’
compensation income or medical benefits if you are injured.
EMPLOYEE ASSISTANCE: The Division provides free information
about how to file a workers’ compensation claim. Division staff
will answer any questions you may have about workers’ compensation
and process any requests for dispute resolution of a claim. You can
obtain this assistance by contacting your local Division field
office or by calling 800.252.7031. The Office of Injured Employee
Counsel (OIEC) also provides free assistance to injured employees
and will explain your rights and responsibilities under the
Workers’ Compensation Act. You can obtain OIEC’s assistance by
contacting an OIEC customer service representative in your local
Division field office or by calling 866-EZE-OIEC
(866.393.6432).
SAFETY HOTLINE: The Division has a 24 hour toll-free telephone
number for reporting unsafe conditions in the workplace that may
violate occupational health and safety laws. Employers are
prohibited by law from suspending, terminating, or discriminating
against any employee because he or she in good faith reports an
alleged occupational health or safety violation. Contact the
Division at 800.452.9595.
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Qualified Medical Child Support Order (QMCSO) Federal law
requires Houston Methodist, under certain circumstances, to provide
health care coverage for your child(ren) when you divorce,
separate, or are even never married, when ordered to do so by State
authorities. The process begins when Houston Methodist receives a
medical child support order. This means any judgment, decree, or
order, including approval of a settlement agreement, which:
Is issued from a court of competent jurisdiction or through an
administrative process established under State law and has the
force and effect of an order under State law pursuant to a state’s
domestic relations law.
Requires you to provide group health coverage for your
child(ren), even though you no longer have custody.
Clearly specifies your name and last known mailing address and
the name and addresses of a child covered by the order. The name
and mailing address of a State or local official may be substituted
for the address of the child.
A reasonable description of the coverage to be provided. The
length of time the order applies.
The Plan Administrator will provide written notification to you
and each identified child for which it has received an order
requiring coverage. Within a reasonable time after the receipt of
the order, the Plan Administrator will determine whether the order
is a Qualified Medical Child Support Order (QMCSO) and notify you
and the child’s legal representative of the determination. This
notice will include any required enrollment material, a description
of the procedures to be followed, and a form for designating the
child’s custodial parent or legal guardian as his or her
representative for all benefit plan purposes. Plan benefits that
have not been assigned will be used to reimburse charges for
covered expenses incurred by an identified child.
Premium Assistance under Medicaid and the Children’s Health
Insurance Program (CHIP) If you or your children are eligible for
Medicaid or CHIP and you’re eligible for health coverage from your
employer, your state may have a premium assistance program that can
help pay for coverage, using funds from their Medicaid or CHIP
programs. If you or your children aren’t eligible for Medicaid or
CHIP, you won’t be eligible for these premium assistance programs
but you may be able to buy individual insurance coverage through
the Health Insurance Marketplace. For more information, visit
www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or
CHIP and you live in a State listed below, contact your State
Medicaid or CHIP office to find out if premium assistance is
available.
If you or your dependents are NOT currently enrolled in Medicaid
or CHIP, and you think you or any of your dependents might be
eligible for either of these programs, contact your State Medicaid
or CHIP office or dial 877.KIDS.NOW or www.insurekidsnow.gov to
find out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an
employer-sponsored plan.
If you or your dependents are eligible for premium assistance
under Medicaid or CHIP, as well as eligible under your employer
plan, your employer must allow you to enroll in your employer plan
if you aren’t already enrolled. This is called a “special
enrollment” opportunity, and you must request coverage within 60
days of being
You must request coverage within 60 days of being determined
eligible for premium assistance.
If Houston Methodist receives a QMCSO, it must permit immediate
enrollment. This means the child(ren) identified will be included
for coverage as your eligible dependent and you will pay the
required premiums. The child’s custodial parent, legal guardian, or
a state agency can make application for the child’s coverage, even
if you do not.
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determined eligible for premium assistance. If you have
questions about enrolling in your employer plan, contact the
Department of Labor at www.askebsa.dol.gov or call 866.444.EBSA
(3272).
If you live in one of the following states, you may be eligible
for assistance paying your employer health plan premiums. The
following list of states is current as of July 31, 2016. Contact
your State for more information on eligibility.
State Website Phone Number ALABAMA – Medicaid
http://myalhipp.com/ 855.692.5447
ALASKA – Medicaid http://myakhipp.com/ (Outside of
Anchorage):
888.318.8890 (Anchorage): 907.269.6529
Arkansas – Medicaid http://myarhipp.com/ 855-692-7447 COLORADO –
Medicaid http://www.colorado.gov/hcpf 800.221.3943 FLORIDA –
Medicaid https://www.flmedicaidtplrecovery.com/ 877.357.3268
GEORGIA – Medicaid http://dch.georgia.gov/ Go to Programs >
Medicaid > Health Insurance Premium Payment (HIPP)
404.656.4507
INDIANA – Medicaid http://www.hip.in.gov 877-438-4479 IOWA –
Medicaid www.dhs.state.ia.us/hipp/ 888.346.9562 KANSAS – Medicaid
http://www.kdheks.gov/hcf/ 785-296-3512 KENTUCKY – Medicaid
http://chfs.ky.gov/dms/default.htm 800.635.2570 LOUISIANA –
Medicaid http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
888.695.2447 MAINE – Medicaid
http://www.maine.gov/dhhs/ofi/public-assistance/index.html
800-442-6003 MASSACHUSETTS – Medicaid and CHIP
http://www.mass.gov/MassHealth 800.462.1120
MINNESOTA – Medicaid http://mn.gov/dhs/ma/ 800.657.3739 MISSOURI
– Medicaid http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
573.751.2005 MONTANA – Medicaid
http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP 800.694.3084
NEBRASKA – Medicaid
http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx
855.632.7633
NEVADA – Medicaid http://dwss.nv.gov/ 800.992.0900 NEW HAMPSHIRE
– Medicaid
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
603.271.5218
NEW JERSEY – Medicaid and CHIP
Medicaid:
http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ CHIP:
http://www.njfamilycare.org/index.html
Medicaid: 609.631.2392 CHIP: 800.701.0710
NEW YORK – Medicaid
http://www.nyhealth.gov/health_care/medicaid/ 800.541.2831 NORTH
CAROLINA – Medicaid
http://www.ncdhhs.gov/dma 919.855.4100
NORTH DAKOTA – Medicaid
http://www.nd.gov/dhs/services/medicalserv/medicaid/
844-854-4825
OKLAHOMA – Medicaid and CHIP
http://www.insureoklahoma.org 888-365-3742
OREGON – Medicaid
http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html 800-699-9075
PENNSYLVANIA – Medicaid
http://www.dhs.state.pa.us/hipp 800.692.7462
RHODE ISLAND – Medicaid
http://www.eohhs.ri.gov/ 401.462.5300
SOUTH CAROLINA – Medicaid
http://www.scdhhs.gov 888.549.0820
SOUTH DAKOTA - Medicaid http://dss.sd.gov 888.828.0059 TEXAS –
Medicaid http://gethipptexas.com/ 800.440.0493
UTAH – Medicaid and CHIP Medicaid:
http://health.utah.gov/medicaid CHIP:
http://health.utah.gov/chip
877-543-7669
VERMONT– Medicaid http://www.greenmountaincare.org/ 800.250.8427
VIRGINIA – Medicaid and CHIP
Medicaid: http://www.coverva.org/programs_premium_assistance.cfm
CHIP: http://www.coverva.org/programs_premium_assistance.cfm
Medicaid: 800.432.5924 CHIP: 855.242.8282
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State Website Phone Number
WASHINGTON – Medicaid
http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program
800.562.3022 ext. 15473
WEST VIRGINIA – Medicaid
http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx
877.598.5820 HMS Third Party Liability
WISCONSIN – Medicaid and CHIP
https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
800.362.3002
WYOMING – Medicaid https://wyequalitycare.acs-inc.com/
307.777.7531
To see if any other states have added a premium assistance
program since July 31, 2016, or for more information on special
enrollment rights, contact either:
U.S. Department of Labor Employee Benefits Security
Administration www.dol.gov/ebsa 866.444.EBSA (3272)
U.S. Department of Health and Human Services Centers for
Medicare & Medicaid Services www.cms.hhs.gov 877.267.2323, Menu
Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
Your Rights Under the Family Medical Leave Act of 1993
(FMLA)
Basic Leave Entitlement FMLA requires covered employers to
provide up to 12 weeks of unpaid, job-protected leave to eligible
employees for the following reasons:
For incapacity due to pregnancy, prenatal medical care or child
birth; To care for the employee’s child after birth, or placement
for adoption or foster care; To care for the employee’s spouse, son
or daughter, or parent, who has a serious health condition; or For
a serious health condition that makes the employee unable to
perform the employee’s job.
Military Family Leave Entitlements Eligible employees with a
spouse, son, daughter, or parent on active duty or call to active
duty status in the National Guard or Reserves in support of a
contingency operation may use their 12-week leave entitlement to
address certain qualifying exigencies. Qualifying exigencies may
include attending certain military events, arranging for
alternative childcare, addressing certain financial and legal
arrangements, attending certain counseling sessions, and attending
post-deployment reintegration briefings.
FMLA also includes a special leave entitlement that permits
eligible employees to take up to 26 weeks of leave to care for a
covered service member during a single 12-month period. A covered
service member is a current member of the Armed Forces, including a
member of the National Guard or Reserves, who has a serious injury
or illness incurred in the line of duty on active duty that may
render the service member medically unfit to perform his or her
duties for which the service member is undergoing medical
treatment, recuperation, or therapy; or is in outpatient status; or
is on the temporary disability retired list.
Benefits and Protections During FMLA leave, the employer must
maintain the employee’s health coverage under any “group health
plan” on the same terms as if the employee had continued to work.
Upon return from FMLA leave, most employees must be restored to
their original or equivalent positions with equivalent pay,
benefits, and other employment terms.
Employees must provide 30 days advance notice of the need to
take FMLA leave when the need is foreseeable. When 30-days notice
is not possible, the employee must provide notice as soon as
practicable and generally must comply with an employer’s normal
call-in procedures
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Use of FMLA leave cannot result in the loss of any employment
benefit that accrued prior to the start of an employee’s leave.
Eligibility Requirements Employees are eligible if they have
worked for a covered employer for at least one year, for 1,250
hours over the previous 12 months, and if at least 50 employees are
employed by the employer within 75 miles.
Definition of Serious Health Condition A serious health
condition is an illness, injury, impairment, or physical or mental
condition that involves either an overnight stay in a medical care
facility, or continuing treatment by a health care provider for a
condition that either prevents the employee from performing the
functions of the employee’s job, or prevents the qualified family
member from participating in school or other daily activities.
Subject to certain conditions, the continuing treatment
requirement may be met by a period of incapacity of more than three
consecutive calendar days combined with at least two visits to a
health care provider or one visit and a regimen of continuing
treatment, or incapacity due to pregnancy, or incapacity due to a
chronic condition. Other conditions may meet the definition of
continuing treatment.
Use of Leave An employee does not need to use this leave
entitlement in one block. Leave can be taken intermittently or on a
reduced leave schedule when medically necessary. Employees must
make reasonable efforts to schedule leave for planned medical
treatment so as not to unduly disrupt the employer’s operations.
Leave due to qualifying exigencies may also be taken on an
intermittent basis.
Substitution of Paid Leave for Unpaid Leave Employees may choose
or employers may require use of accrued paid leave while taking
FMLA leave. In order to use paid leave for FMLA leave, employees
must comply with the employer’s normal paid leave policies.
Employee Responsibilities Employees must provide sufficient
information for the employer to determine if the leave may qualify
for FMLA protection and the anticipated timing and duration of the
leave. Sufficient information may include that the employee is
unable to perform job functions, the family member is unable to
perform daily activities, the need for hospitalization or
continuing treatment by a health care provider, or circumstances
supporting the need for military family leave. Employees also must
inform the employer if the requested leave is for a reason for
which FMLA leave was previously taken or certified. Employees also
may be required to provide a certification and periodic
recertification supporting the need for leave.
Employer Responsibilities Covered employers must inform
employees requesting leave whether they are eligible under FMLA. If
they are, the notice must specify any additional information
required as well as the employees’ rights and responsibilities. If
they are not eligible, the employer must provide a reason for the
ineligibility.
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Covered employers must inform employees if leave will be
designated as FMLA-protected and the amount of leave counted
against the employee’s leave entitlement. If the employer
determines that the leave is not FMLA-protected, the employer must
notify the employee.
Unlawful Acts by Employers FMLA makes it unlawful for any
employer to:
Interfere with, restrain, or deny the exercise of any right
provided under FMLA
Discharge or discriminate against any person for opposing any
practice made unlawful by FMLA or for involvement in any proceeding
under or relating to FMLA
Enforcement An employee may file a complaint with the U.S.
Department of Labor or may bring a private lawsuit against an
employer. FMLA does not affect any Federal or State law prohibiting
discrimination, or supersede any State or local law or collective
bargaining agreement which provides greater family or medical leave
rights.
Uniformed Services Employment and Reemployment Rights Act of
1994 (USERRA) USERRA protects the job rights of individuals who
voluntarily or involuntarily leave employment positions to
undertake military service or certain types of service in the
National Disaster Medical System. USERRA also prohibits employers
from discriminating against past and present members of the
uniformed services, and applicants to the uniformed services.
Reemployment Rights You have the right to be reemployed in your
civilian job if you leave that job to perform service in the
uniformed service and you:
Ensure that your employer receives advance written or verbal
notice of your service; Have five years or less of cumulative
service in the uniformed services while with that particular
employer; Return to work or apply for reemployment in a timely
manner after conclusion of service; and Have not been separated
from service with a disqualifying discharge or under other than
honorable
conditions.
If you are eligible to be reemployed, you must be restored to
the job and benefits you would have attained if you had not been
absent due to military service or, in some cases, a comparable
job.
Right to Be Free from Discrimination and Retaliation If you are
a past or present member of the uniformed service, have applied for
membership in the uniformed service, or are obligated to serve in
the uniformed service, then an employer may not deny you initial
employment, reemployment, retention in employment, promotion, or
any benefit of employment because of this status.
For Additional Information on Family Medical Leave If you have
access to the Internet, visit the FMLA website:
http://www.dol.gov/esa/whd/fmla. To locate your nearest Wage-Hour
Office, telephone the Wage-Hour toll-free information and help line
at 1-866-4USWAGE (1-866-487-9243). A customer service
representative is available to assist you with referral information
from 8 a.m. to 5 p.m. in your time zone; or access online at
http://www.wagehour.dol.gov.
Employee Benefits Security Administration Centers for Medicare
& Medicaid Services: www.dol.gov/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
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In addition, an employer may not retaliate against anyone
assisting in the enforcement of USERRA rights, including testifying
or making a statement in connection with a proceeding under USERRA,
even if that person has no service connection.
Health Insurance Protection If you leave your job to perform
military service, you have the right to elect to continue your
existing employer-based health plan coverage for you and your
dependents for up to 24 months while in the military.
Even if you don't elect to continue coverage during your
military service, you have the right to be reinstated in your
employer's health plan when you are reemployed, generally without
any waiting periods or exclusions (e.g., pre-existing condition
exclusions) except for service-connected illnesses or injuries.
Enforcement The U.S. Department of Labor, Veterans Employment
and Training Service (VETS) is authorized to investigate and
resolve complaints of USERRA violations. For assistance in filing a
complaint, or for any other information on USERRA, contact VETS at
1-866-4-USA-DOL or visit its website at http://www.dol.gov/vets. An
interactive online USERRA Advisor can be viewed at
http://www.dol.gov/elaws/userra.htm. If you file a complaint with
VETS and VETS is unable to resolve it, you may request that your
case be referred to the Department of Justice or the Office of
Special Counsel, as applicable, for representation.
You should contact HR Benefits at 832-667-6211 or
[email protected] if you have questions about your
rights to continue health coverage under USERRA.
The Employee Retirement Income Security Act of 1974 (ERISA)
Your Rights As a participant in a benefit plan, you are entitled
to certain rights and protections under the Employee Retirement
Income Security Act of1974 (ERISA). ERISA provides that all
participants shall be permitted to:
Receive information about your plan and benefits Examine,
without charge, at the Plan Administrator’s office and at other
specified locations, such as
worksites and union halls, all documents governing the plan,
including pertinent insurance contracts, trust agreements,
collective bargaining agreements, a copy of the latest summary
annual report (Form 5500 Series), and other documents filed by the
plan with the Internal Revenue Service or 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 a benefit plan, including
insurance contracts and collective bargaining agreements, and
copies of the latest annual report (Form 5500 Series) and updated
Summary Plan Description.
Receive a summary of the plan’s annual financial activities. The
Plan Administrator is required by law to furnish each participant
with a copy of the summary annual report.
Prudent Actions by Plan Fiduciaries In addition to creating
rights for participants, ERISA imposes duties upon the people who
are responsible for the operation of the employee benefit plan. The
people who operate your plan, called “fiduciaries” of the plan,
have a duty to do so prudently and in the interest of you and other
plan participants and beneficiaries. No one, including your
employer, your union, or any other person may fire you or otherwise
discriminate against you in any way to prevent you from obtaining a
welfare benefit or exercising your rights under ERISA.
Enforce Your Rights If your claim for a welfare benefit is
denied or ignored, in whole or in part, you have a right to know
why this was done, to obtain copies of documents relating to the
decision without charge, and to appeal any denial, all within
certain time schedules. Under ERISA, there are steps you can take
to enforce the above rights. For instance, if
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you request a copy of plan documents or the latest annual report
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, and you have exhausted the administrative remedies
available under the benefit plan, you may file suit in a state or
Federal court. In addition, if you disagree with the 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 the benefit plan
fiduciaries misuse the benefit 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 Your Questions If you have any questions about a
benefit plan, you should contact the Plan Administrator. If you
have any questions about this statement or about your rights under
ERISA, or if you need assistance in obtaining documents from the
Plan Administrator, you should contact the nearest office of the
Employee Benefits Security Administration, U.S. Department of Labor
listed in your telephone directory or write to 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 at 800-998-7542.
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October 2016