Directory of Benefits
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Patient/Physician Cooperatives (PPC)
Directory of Benefits
Patient Association PPC Membership
This is a Healthcare Cooperative between patients and physicians that includes guaranteed pricing for healthcare at fair and reasonable prices for members, using the cooperative member physicians, contracted networks, and participating facilities.
Patient /Physician Cooperatives (PPC) gives the local medical cooperative proper governance and helps it recruit the individual patient and physician members. PPC contracts with physicians in Accountable Care Organizations (ACOs) and Independent Practice Associations (IPAs). These groups each have physicians as members in primary care practices and in specialty practices.
PPC surveyed patients about their abilities to pay monthly for primary healthcare services. Based on the survey, PPC found that patients said they could better budget if there was a fixed monthly cost for primary healthcare services. The participating physicians in the ACOs and IPAs found that fixed cost funding collecting in monthly payments allowed for better budgeting within the physicians office, reduce physician overhead and was adequate to care for an individual patient provided the contract for a member would was from year to year.
The fees were established as a direct payment agreement between the physician and his or her patient, which PPC named “Concierge and Concierge Plus.”
None of the listed benefits of the Patient Physician Cooperatives are insurance, except for an Association Group Hospital Indemnity Policy and Group Stop Loss Reinsurance.
The plan (not including the Group Hospital Indemnity Policy and Stop Loss Policy) provides discounts at certain healthcare providers of medical services. The plan member is obligated to pay for all healthcare services but will receive a discount from those healthcare providers who have contracted with the discount plan organization.
In several states, primary care services, lab and diagnostic are paid for through the Concierge or Concierge Plus Monthly Retainer Payment Agreements directly between provider and patient member. In other locations, the lab and imaging services are based on fee-for-service at discounted rates, payable at the time of service.
The discount card program is purchased by PPC from Doc Wellbee, Inc. It contains a 30-day cancellation period. Members shall receive a full refund of membership fees, excluding registration fee, if membership is canceled within the first 30 days after the effective date.
Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written and operates subject to state regulations. Teladoc does not prescribe DEA controlled substances. Teladoc physicians reserve the right to deny care for potential misuse of services. Teladoc, Inc. © 2002-2018.
Pharmacy program is not insurance and are not intended as a substitute for insurance. The pharmacy program is only available at participating pharmacies.
What is PPC and How is it Different from an Insurance plan?
Patient/Physician Cooperatives (PPC), is a Texas Non-Profit, as defined by the Texas Business Organizations Code whose goal is to educate on engagement with the healthcare system and to bring an innovative approach to health care services for all citizens and to develop membership in all of the communities where its business is conducted.
Membership Agreement with Doc Wellbee
This Membership Contract Agreement and the membership card constitutes the entire agreement.
Plan Type: Association
Plan Name: Patient/Physician Cooperatives
Family plan membership includes all legal dependents.
Disclosures and limitations:
▪ The advertised plan is not a health insurance policy.
▪ The advertised plan provides discounts at certain healthcare providers for medical services.
▪ The advertised plan does not make payments directly to the providers of medical services.
▪ The advertised plan member is obligated to pay for all healthcare services but will receive a discount from
those healthcare providers who have contracted with the discount plan organization.
▪ The Discount Medical Plan Organization is Doc Wellbee, Inc, located at 3957 Pleasantdale Rd. Suite 102,
Atlanta, GA 30340.
Please visit the Doc Wellbee website: www.docwellbee.com for a current fee schedule and listing of Dental Providers located near you.
The contract effective date is the date of the individual PPC membership and shall remain in effect until terminated.
Termination of membership: Doc Wellbee requires a written notice from PPC for the member a minimum of 30 days prior to desired cancellation date. If the member cancels his or her membership with Doc Wellbee within the first 30 days after the effective date of enrollment in the plan, the member shall receive a reimbursement within 30 days of all periodic charges upon return of the discount cards to PPC.
For questions, complaints, or concerns regarding membership or plan benefits, please call Doc Wellbee Monday through Friday (8:30 a.m. - 5:30 p.m. EST) to speak with a representative.
Benefit Types for Each Plan Being Offered
Discounted Healthcare Rates for cash-at-time-of-service (based on prices set near Medicare Rates).
A. Basic Membership in the Cooperative
B. Concierge, Concierge Plus, and Concierge Elite Medical Care
C. Lab Tests
D. Diagnostic Imaging
E. Teladoc - Consult via Phone
F. Dental Care Discounts
G. Vision Care Discounts
H. Prescription Drug through Drexi
I. Hearing Care & Hearing Aid Discounts
J. 7/24/365 Roadside Assistance Services
K. Patient Advocacy
L. Group Hospital Indemnity Insurance
M. Group Lump Sum Cancer Insurance
N. Stop Loss Insurance
O. Health Club Membership (Houston Only)
P. Health Debit Card
Type of Benefits in each Plan
Basic A, C, E, F, G, H, I, J, K (Discounts + Lab)
Concierge A, B, C, E, F, G, H, I, J, K (Basic + PCP retainer or P)
Concierge Plus A, B, C, D, E, F, G, H, I, J, K, & P (Concierge + Imaging retainer or P)
Members with any of membership plans the above may purchase the association group insurance policies issued by the applicable insurance company.
Hospital indemnity Coverage: Policy # 98210-02 the benefits summary is available upon request (L)
Group Lump Sum Cancer Coverage: Through Pan American (M)
Stop-Loss reinsurance: Policy # 11835 the benefits summary is available upon request (N)
Plan Benefits Summaries
Basic Membership in the Association (A)
Services from PPC medical providers that are not covered by group insurance as in types (L), (M), and (N) or are not based on a monthly payment plan. Whereas types (B), (C) and (D) are paid for with cash, check or credit card at the time of service based on direct contract prices or discounts offered by providers and vendors. Each person in the Association has this benefit and each adult member is entitled to a vote at the annual meeting.
Concierge, Concierge Plus Medical Care (B)
Primary medical care services are provided to members with no co-payment and no health qualifications. Members choose their primary care physician (PCP) from the PPC Provider Directory, from among listed Family Practitioners, Internists, General Practitioners, Masters or Doctors of Eastern Medicine, and Naturopaths. Each member signs a monthly payment plan agreement with his or her chosen PCP. This payment entitles the member to fixed amount of retained of services per year from the PCP based on contracted prices. If during the year the member exceeds the services as allowed under the retainer agreement (typically no more than 6 visits), then additional services are paid for at the cash rate charged by the chosen providers office for each additional visit.
Lab Tests (C)
Each member in all plans have lab services available from Clinical Pathology Laboratories (CPL) or Quest. In some cases, the choice of Primary Care Physician may drive lab selection.
A simple blood test is necessary for the prevention or early detection of diseases. The earlier a problem is identified, the easier and more likely it is to be treated.
*Not ALL labs tests are covered at $0 additional plan cost. See lab test exclusions list.
Diagnostic Imaging (D)
Selected freestanding imaging centers in several cities offer PPC members a monthly payment plan in which there is $0 payment at the time of service. Members who choose services from an imaging center other than the one selected during enrollment are subject to direct billing from the imaging center.
These centers are listed in the PPC Provider Directory.
Teladoc (E) (800-835-2362)
Telemedicine is comprised of a national network of U.S. board-certified physicians who use electronic health records, telephone consultations and online video consultations to diagnose, recommend treatment and write short-term, non-DEA controlled prescriptions, when appropriate.
Physicians are available 24 hours a day, 365 days a year. This allows PPC membersof any ageto conveniently access quality care from their home, work or on the go as opposed to more expensive and time-consuming alternatives like the doctor’s office or emergency room.
To ensure high-quality physicians, credentials for physicians are conducted every two years. They are Page 9 of 19
also subject to a 10% random audit, which exceed NCQA standards.
When Do You Use Telemedicine?
When Do You Use Telemedicine?
- When your physician is not available
- After hours or whenever you need non-emergency care - On vacation, or on a business trip
- If you are considering a trip to the emergency room or urgent care center
for non-emergency treatment
What conditions would you use Telemedicine for? (Not an inclusive list)
- For non-emergency care such as cold or flu
- Sinus infection
- Respiratory infection
- Pink eye
- Urinary tract infections
- Poison ivy
- Some skin disorders
Dental Care Discounts (F) (800-290-0523)
Members may take advantage of savings offered by an industry leader in dental care, from Doc Wellbee. Doc Wellbee has a recognized professional dental network that of over 100,000 dental access points.
Dental Plan Features
▪ 20% to 50% savings on most dental procedures including routine oral exams, and major work such as dentures, root canals, and crowns.
▪ Unlimited cleanings.
▪ 20% savings on orthodontics including braces and retainers for children and adults.
▪ 20% reduction on specialist’s normal fees. Specialties include Endodontics, Oral Surgery, Pediatric Dentistry, Periodontics, and Prosthodontics where available.
▪ Cosmetic dentistry such as bonding and veneers also included.
▪ All dentists must meet highly selective credentialing standards based on education, background, license standing and other requirements.
▪ Members may visit any participating dentist on the plan and change providers at any time.
· See the Doc Wellbee wage page at https://docwellbee.com/index.php/dental-plan for the most current plan rates and savings.
Vision Care (G)
Members save 20% to 40% off the retail price of eyewear with the EyeMed Vision Care Access Plan D discount program through the Access network. Members are eligible for discounts on exams, eyeglasses and contact lenses from more than 65,000 providers nationwide including independent optometrists, ophthalmologists, opticians, and leading optical retailers such as LensCrafters®, Sears Optical® Target Optical®, JCPenney® Optical, and most Pearle Vision® locations.
- Replacement Contact Lenses by Mail - EyeMed members may order replacement contact lenses via the Internet and have them mailed directly to the member’s home. This service is for replacement contact lenses only, and the EyeMed discount does not apply. The member’s initial pair of contact lenses must still be purchased from their eye care provider to ensure proper fit and follow-up.
Serving you with choice, quality, and savings.
▪ Members will receive savings of 40% to 50% off the overall national average cost for traditional LASIK surgery through QualSight or
receive significant savings on newer procedures like Custom Bladeless (all laser) LASIK.
▪ QualSight has more than 750 locations, so members can choose the provider and the LASIK procedure that meets their vision care needs.
▪ QualSight is contracted with credentialed and experienced physicians who have collectively performed over 4 million procedures.
The QualSight program is not an insured program.
Prescription Drugs- Through Drexi (H)
Save on prescription drugs from thousands of pharmacies nationwide. All the major pharmacies have access via their computers to the pricing for your drugs based on your health plan. Your RX Bin Number, your Group Number, and your Plan Code are printed on your ID card. There is also a helpline number for your pharmacist if there are any questions about the plan or prices.
Save 40% off diagnostic services from the HearPO program, including hearing exams and significant discounts on the price of hearing aids at over 3,200 provider locations nationwide.
Includes one year of free batteries (80 cell per hearing aid).
Lowest Price Guarantee*: If you should find a lower price at another local provider, we’ll gladly beat that price by 5%.
*Competitor coupon required for verification of price and model. Limited to manufacturers offered through the HearPO program. Local Provider quotes only will be matched.
Roadside Assistance (J)
Towing - When a member’s automobile is disabled as a result of a covered breakdown, we will arrange to have it towed home or to the nearest qualified service facility.
Flat Tire - If the member’s vehicle has an operable spare tire, it will be installed to replace a flat tire. If the vehicle has two or more flat tires or it does not have an operable spare, the vehicle will be towed in accordance with the towing benefit.
Fuel, Oil, and Fluid Delivery Service - If the vehicle runs out of fuel or fluids, we will provide for the delivery of fuel or other fluids needed at the disablement site. Specific brands or octane ratings cannot be ensured (Does not cover the cost of fuel or fluids).
Battery Service - When a member’s vehicle experiences battery failure, we will provide a jump-start.
Lock-out Assistance - When a member loses their key or locks them in their vehicle, service will be sent to gain entry (Does not cover costs to reproduce keys).
Winching/Vehicle Extraction - - Customer vehicle will be winched if stuck in a ditch, mud or snow as long as it is accessible from a normally traveled roadway.
PPC believes this service has an important place in healthcare because it may prevent accidents and injuries by keeping members from attempting to perform these repairs on the road and in traffic.
Patient Advocacy (K)
PPC helps members deal with important matters related to receiving healthcare services and resolving healthcare paperwork hassles and red tape. Having a professional patient advocate in settling bills and expenses in and outside the PPC network of providers helps give members peace of mind. ~ Se habla Español.
Group Hospital Indemnity Insurance (L)
Hospital confinement indemnity coverage is designed to provide members with a fixed daily benefit during periods of hospital confinement resulting from a covered injury or sickness.
Group Lump Sum Cancer Insurance (M)
Lump Sum Cancer policy that pays a fixed amount of 25k for a cancer diagnosis that occurs post enrollment.
Stop Loss Insurance (N)
A policy that covers 90% of the hospital cost above 50k up to 5 million dollars.
Health Club Membership (O)
Physical fitness and exercise are an important part of health and wellness. PPC has made arrangements with the Downtown Club and the Met in the Houston Texas service area to use their facilities for our members.
Health Debit Card (HDC) (P)
Health Reimbursement Arrangement; Transition to consumer-driven healthcare by giving employees and their families a simple way to save for, manage, and spend employer-provided healthcare funds. With an HRA, your company employees can set aside a certain amount of dollars per month in an account to pay for hundreds of eligible healthcare expenses. View The PDF File for more information.
The listing of medical practices can be found on the PPC website at:
For assistance in finding a physician in your area, you may also call our helpline at:
If you have a personal physician who is not in our cooperative and you want to nominate him or her to be part of the medical team, we will be glad to invite him or her to become a member.
The Plan provides each member with a separate Notice of Privacy Practices. This Notice describes how the Plan uses and discloses your personal health information. It also describes certain rights you have regarding this information. Additional copies of our Notice of Privacy Practices are available by calling the Plan Sponsor at 866-549-4199.
Definitions • Breach means an unauthorized acquisition, access, use or disclosure of Protected Health Information (“PHI”) or Electronic Protected Health Information (“ePHI”) that violates the HIPAA Privacy Rule and that compromises the security or privacy of the information. • Protected Health Information (“PHI”) means individually identifiable health information, as defined by HIPAA, that is created or received by us and thatrelates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual or for which there is a reasonable basis to believe the information can be used to identify the individual. PHI includes information of persons living or deceased.
Commitment to Protecting Health Information The Plan will comply with the Standards for Privacy of Individually Identifiable Health Information (i.e., the “Privacy Rule”) set forth by the U.S. Department of Health and Human Services (“HHS”) pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Such standards control the dissemination of “protected health information” (“PHI”) of Participants. Privacy Standards will be implemented and enforced in the offices of the Employer and Plan Sponsor and any other entity that may assist in the operation of the Plan.
The Plan is required by law to take reasonable steps to ensure the privacy of the Participant’s PHI, and inform him/her about:
1. The Plan’s disclosures and uses of PHI; 2. The Participant’s privacy rights with respect to his/her PHI; 3. The Plan’s duties with respect to his/her PHI; 4. The Participant’s right to file a complaint with the Plan and with the Secretary of HHS; and 5. The person or office to contact for further information about the Plan’s privacy practices. Within this provision capitalized terms may be used, but not otherwise defined. These terms shall have the same meaning as those terms set forth in 45 CFR Sections 160.103 and 164.501. Any HIPAA regulation modifications altering a defined HIPAA term or regulatory citation shall be deemed incorporated into this provision.
How Health Information May be Used and Disclosed In general, the Privacy Rules permit the Plan to use and disclose, the minimum necessary amount, an individual’s PHI, without obtaining authorization, only if the use or disclosure is:
1. To carry out Payment of benefits; 2. For Health Care Operations; 3. For Treatment purposes; or 4. If the use or disclosure falls within one of the limited circumstances described in the rules (e.g., the disclosure is required by law or for public health activities).
Disclosure of PHI to the Plan Sponsor for Plan Administration Purposes In order that the Plan Sponsor may receive and use PHI for plan administration purposes, the Plan Sponsor agrees to:
1. Not use or further disclose PHI other than as permitted or required by the Plan documents or as required by law (as defined in the Privacy Standards); 2. Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the Plan, agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such PHI; 3. Establish safeguards for information, including security systems for data processing and storage; 4. Maintain the confidentiality of all PHI, unless an individual gives specific consent or authorization to disclose such data or unless the data is used for health care payment or Plan operations; 5. Receive PHI, in the absence of an individual’s express authorization, only to carry out Plan administration functions; 6. Not use or disclose genetic information for underwriting purposes; 7. Not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or Employee benefit plan of the Plan Sponsor, except pursuant to an authorization which meets the requirements of the Privacy Standards; 8. Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which the Plan Sponsor becomes aware; 9. Make available PHI in accordance with section 164.524 of the Privacy Standards (45 CFR 164.524); 10. Make available PHI for amendment and incorporate any amendments to PHI in accordance with section 164.526 of the Privacy Standards (45 CFR 164.526); 11. Make available the information required to provide an accounting of disclosures in accordance with section 164.528 of the Privacy Standards (45 CFR 164.528); 12. Make its internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of the U.S. Department of Health and Human Services (“HHS”), or any other officer or Employee of HHS to whom the authority involved has been delegated, for purposes of determining compliance by the Plan with part 164, subpart E, of the Privacy Standards (45 CFR 164.500 et seq); 13. Report to the Plan any inconsistent uses or disclosures of PHI of which the Plan Sponsor becomes aware; 14. Train Employees in privacy protection requirements and appoint a privacy compliance coordinator responsible for such protections; 15. If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the PHI infeasible; and 16. Ensure that adequate separation between the Plan and the Plan Sponsor, as required insection 164.504(f)(2)(iii) of the Privacy Standards (45 CFR 164.504(f)(2)(iii)), is established as follows: a. The following Employees, or classes of Employees, or other persons under control of the Plan Sponsor, shall be given access to the PHI to be disclosed: i. Privacy Officer: The access to and use of PHI by the individuals described above shall be restricted to the plan administration functions that the Plan Sponsor performs for the Plan.
In the event any of the individuals described above do notcomply with the provisions of the Plan documents relating to use and disclosure of PHI, the Plan Administrator shall impose reasonable sanctions as necessary, in its discretion, to ensure that no further non-compliance occurs. The Plan Administrator will promptly report such violation or non-compliance to the Plan and will cooperate with the Plan to correct violation or non-compliance and to impose appropriate disciplinary action or sanctions. Such sanctions shall be imposed progressively (for example, an oral warning, a written warning, time off without pay and termination), if appropriate, and shall be imposed so that they are commensurate with the severity of the violation.
Disclosure of Summary Health Information to the Plan Sponsor the Plan may disclose PHI to the Plan Sponsor of the group health plan for purposes of plan administration or pursuant to an authorization request signed by the Participant. The Plan may use or disclose “summary health information” to the Plan Sponsor for obtaining premium bids or modifying, amending, or terminating the group health plan.
Disclosure of Certain Enrollment Information to the Plan Sponsor Pursuant to section 164.504(f)(1)(iii) of the Privacy Standards (45 CFR 164.504(f)(1)(iii)), the Plan may disclose to the Plan Sponsor information on whether an individual is participating in the Plan or is enrolled in or has un-enrolled from a health insurance issuer or health maintenance organization offered by the Plan to the Plan Sponsor.
Disclosure of PHI to Obtain Stop-loss or Excess Loss Coverage The Plan Sponsor may hereby authorize and direct the Plan, through the Plan Administrator or the Third Party Administrator, to disclose PHI to stop-loss carriers, excess loss carriers or managing general underwriters (“MGUs”) for underwriting and other purposes in order to obtain and maintain stop-loss or excess loss coverage related to benefit claims under the Plan. Such disclosures shall be made in accordance with the Privacy Standards.
Other Disclosures and Uses of PHI:
Primary Uses and Disclosures of PHI 1. Treatment, Payment and Health Care Operations: The Plan has the right to use and disclose a Participant’s PHI for all activities as included within the definitions of Treatment, Payment, and Health Care Operations and pursuant to the HIPAA Privacy Rule; 2. Business Associates: The Plan contracts with individuals and entities (Business Associates) to perform various functions on its behalf. In performance of these functions or to provideservices, Business Associates will receive, create, maintain, use, or disclose PHI, but only after the Plan and the Business Associate agree in writing to contract terms requiring the Business Associate to appropriately safeguard the Participant’s information; and 3. Other Covered Entities: The Plan may disclose PHI to assist health care Providers in connection with their treatment or payment activities or to assist other covered entities in connection with payment activities and certain health care operations. For example, the Plan may disclose PHI to a health care Provider when needed by the Provider to render treatment to a Participant, and the Plan may disclose PHI to another covered entity to conduct health care operations. The Plan may also disclose or share PHI with other insurance carriers (such as Medicare, etc.) in order to coordinate benefits, if a Participant has coverage through another carrier.
Other Possible Uses and Disclosures of PHI 1. Required by Law: The Plan may use or disclose PHI when required by law, provided the use or disclosure complies with and is limited to the relevant requirements of such law; 2. Public Health and Safety: The Plan may use or disclose PHI when permitted for purposes of public health activities, including disclosures to: a. A public health authority or other appropriate government authority authorized by law to receive reports of Child abuse or neglect; b. Report reactions to medications or problems with products or devices regulated by the Federal Food and Drug Administration or other activities related to quality, safety, or effectiveness of FDA-regulated products or activities; c. Locate and notify persons of recalls of products they may be using; and d. A person who may have been exposed to a communicable Disease or may otherwise be at risk of contracting or spreading a Disease or condition, if authorized by law; 3. The Plan may disclose PHI to a government authority, except for reports of Child abuse or neglect, when required or authorized by law, or with the Participant’s agreement, if the Plan reasonably believes he/she to be a victim of abuse, neglect, or domestic violence. In such case, the Plan will promptly inform the Participant that such a disclosure has been or will be made unless the Plan believes that informing him/her would place him/her at risk of serious harm (but only to someone in a position to help prevent the threat). Disclosure generally may be made to a minor’s parents or other representatives although there may be circumstances under Federal or State law when the parents or other representatives may not be given access to the minor’s PHI; 4. Health Oversight Activities: The Plan may disclose PHI to a health oversight agency for oversight activities authorized by law. This includes civil, administrative or criminal investigations; inspections; claim audits; licensure or disciplinary actions; and other activities necessary for appropriate oversight of a health care system, government health care program, and compliance with certain laws; 5. Lawsuits and Disputes: The Plan may disclose PHI when required for judicial or administrative proceedings. For example, the Participant’s PHI may be disclosed in response to a subpoena, discovery requests, or other required legal processes when the Plan is given satisfactory assurances that the requesting party has made a good faith attempt to advise the Participant of the request or to obtain an order protecting such information, and done in accordance with specified procedural safeguards; 6. Law Enforcement: The Plan may disclose PHI to a law enforcement official when required for law enforcement purposes concerning identifying or locating a suspect, fugitive, material witness or missing person. Under certain circumstances, the Plan may disclose the Participant’s PHI in response to a law enforcement official’s request if he/she is, or are suspected to be, a victim of a crime and if it believes in good faith that the PHI constitutes evidence of criminal conduct that occurred on the Sponsor’s or Plan’s premises; 7. Decedents: The Plan may disclose PHI to family members or others involved in decedent’s care or payment for care, a coroner, funeral director or medical examiner for the purpose of identifying a deceased person, determining a cause of death or asnecessary to carry out their duties as authorized by law. The decedent’s health information ceases to be protected after the individual is deceased for 50 years; 8. Research: The Plan may use or disclose PHI for research, subject to certain limited conditions; 9. To Avert a Serious Threat to Health or Safety: The Plan may disclose PHI in accordance with applicable law and standards of ethical conduct, if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a threat to health or safety of a person or to the public; 10. Workers’ Compensation: The Plan may disclose PHI when authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law; and 11. Military and National Security: The Plan may disclose PHI to military authorities of armed forces personnel under certain circumstances. As authorized by law, the Plan may disclose PHI required for intelligence, counter-intelligence, and other national security activities to authorized Federal officials.
Required Disclosures of PHI 1. Disclosures to Participants: The Plan is required to disclose to a Participant most of the PHI in a Designated Record Set when the Participant requests access to this information. The Plan will disclose a Participant’s PHI to an individual who has been assigned as his/her representative and who has qualified for such designation in accordance with the relevant State law. Before disclosure to an individual qualified asa personal representative, the Plan must be given written supporting documentation establishing the basis of the personal representation.
The Plan may elect not to treat the person as the Participant’s personal representative if it has a reasonable belief that the Participant has been, or may be, subjected to domestic violence, abuse, or neglect by such person, it is not in the Participant’s best interest to treat the person as his/her personal representative, or treating such person as his/her personalrepresentative could endanger the Participant; and
Disclosures to the Secretary of the U.S. Dept of Health and Human Services: The Plan is required to disclose the Participant’s PHI to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining the Plan’s compliance with the HIPAA Privacy Rule.
Instances When Required Authorization Is Needed from Participants Before Disclosing PHI
1. Uses and disclosures for marketing; 2. Sale of PHI; and 3. Other uses and disclosures not described in this section can only be made with authorization from the Participant. The Participant may revoke this authorization at any time.
Participant’s Rights the Participant has the following rights regarding PHI about him/her:
1. Request Restrictions: The Participant has the right to request additional restrictions on the use or disclosure of PHI for treatment, payment, or health care operations. The Participant may request that the Plan restrict disclosures to family members, relatives, friends or other persons identified by him/her who are involved in his/her care or payment for his/her care. The Plan is not required to agree to these requested restrictions; 2. Right to Receive Confidential Communication:The Participant has the right to request that he/she receive communications regarding PHI in a certain manner or at a certain location. The request must be made in writing and how the Participant would like to be contacted. The Plan will accommodate all reasonable requests; 3. Right to Receive Notice of Privacy Practices: The Participant is entitled to receive a paper copy of the plan’s Notice of Privacy Practices at any time. To obtain a paper copy, contact the Privacy Compliance Coordinator; 4. Accounting of Disclosures: The Participant has the right to request an accounting of disclosures the Plan has made of his/her PHI. The request must be made in writing and does not apply to disclosures for treatment, payment, health care operations, and certain other purposes. The Participant is entitled to such an accounting for the 6 years prior to his/her request. Except as provided below, for each disclosure, the accounting will include: (a) the date of the disclosure, (b) the name of the entity or person who received the PHI and, if known, the address of such entity or person; (c) a description of the PHI disclosed, (d) a statement of the purpose of the disclosure that reasonably informs the Participant of the basis of the disclosure, and certain other information. If the Participant wishes to make a request, please contact the Privacy Compliance Coordinator; 5. Access: The Participant has the right to request the opportunity to look at or get copies of PHI maintained by the Plan about him/her in certain records maintained by the Plan. If the Participant requests copies, he/she may be charged a fee to cover the costs of copying, mailing, and other supplies. To inspect or copy PHI, or to have a copy of your PHI transmitted directly to another designated person, contact the Privacy Compliance Coordinator. A request to transmit PHI directly to another designated person must be in writing, signed by the Participant and the recipient must be clearly identified. The Plan must respond to the Participant’s request within 30 days (in some cases, the Plan can request a 30 day extension). In very limited circumstances, the Plan may deny the Participant’s request. If the Plan denies the request, the Participant may be entitled to a review of that denial; 6. Amendment: The Participant has the right to request that the Plan change or amend his/her PHI. The Plan reserves the right to require this request be in writing. Submit the request to the Privacy Compliance Coordinator. The Plan may deny the Participant’s request incertain cases, including if it is not in writing or if he/she does not provide a reason for the request; and 7. Fundraising contacts: The Participant has the right to opt out of fundraising contacts.
Questions or Complaints If the Participant wants more information about the Plan’s privacy practices, has questions or concerns, or believes that the Plan may have violated his/her privacy rights, please contact the Plan using the following information. The Participant may submit a written complaint to theU.S. Department of Health and Human Services or with the Plan. The Plan will provide the Participant with the address to file his/her complaint with the U.S. Department of Health and Human Services upon request.
The Plan will not retaliate against the Participant for filing a complaint with the Plan or the U.S. Department of Health and Human Services. For Privacy Compliance Coordinator Contact Information, please contact the Plan Sponsor at the number indicated in Article II Purpose of Plan: General Information.
Disclosure of Electronic Protected Health Information (“Electronic PHI”) to the Plan Sponsor for Plan Administration Functions STANDARDS FOR SECURITY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (“SECURITY RULE”) The Security Rule imposes regulations for maintaining the integrity, confidentiality and availability of protected health information that it creates, receives, maintains, or maintains electronically that is kept in electronic format (ePHI) as required under the Health Insurance Portability and Accountability Act (HIPAA).
Definitions • Electronic Protected Health Information (ePHI), as defined in Section 160.103 of the Security Standards (45 C.F.R. 160.103), means individually identifiable health information transmitted or maintained in any electronic media. • Security Incidents, as defined within Section 164.304 of the Security Standards (45 C.F.R. 164.304), means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with systems operation in an information system.
Plan Sponsor Obligations To enable the Plan Sponsor to receive and use Electronic PHI for Plan Administration Functions (as defined in 45 CFR §164.504(a)), the PlanSponsor agrees to:
1. Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the Electronic PHI that it creates, receives, maintains, or transmits on behalf of the Plan; 2. Ensure that adequate separation between the Plan and the Plan Sponsor, as required in 45 CFR § 164.504(f)(2)(iii), is supported by reasonable and appropriate Security Measures; 3. Ensure that any agent, including a subcontractor, to whomthe Plan Sponsor provides Electronic PHI created, received, maintained, or transmitted on behalf of the Plan, agrees to implement reasonable and appropriate administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of the Electronic PHI and report to the Plan any security incident of which it becomes aware; and
4. Report to the Plan any security incident of which it becomes aware.
Notification Requirements in the Event of a Breach of Unsecured PHI Therequired breach notifications are triggered upon the discovery of a breach of unsecured PHI. A breach is discovered as of the first day the breach is known, or reasonably should have been known. When a breach of unsecured PHI is discovered, the Plan will:
1. Notify the Participant whose PHI has been, or is reasonably believed to have been, assessed, acquired, used, or disclosed as a result of the breach, in writing, without unreasonable delay and in no case later than 60 calendar days after discovery of the breach. Breach Notification must be provided to individual by a. Written notice by first-class mail to Participant (or next of kin) at last known address or, if specified by Participant, e-mail; b. If Plan has insufficient or out-of-date contact information for the Participant, the Participant must be notified by a “substitute form, c. If an urgent notice is required, Plan may contact the Participant by telephone. i. The Breach Notification will have the following content: 1. Brief description of what happened, including date of breach and date discovered; 2. Types of unsecured PHI involved (e.g., name, Social Security number, date of birth, home address, account number); 3. Steps Participant should take to protect from potential harm; 4. What the Plan is doing to investigate the breach, mitigate losses and protect against further breaches; 2. Notify the media if the breach affected more than 500 residents of a State or jurisdiction. Notice must be provided to prominent media outlets serving the State or jurisdiction without unreasonable delay and in no case later than 60 calendar days after the date the breach was discovered; 3. Notify the HHS Secretary if the breach involves 500 or more individuals, contemporaneously with the notice to the affected individual and in the manner specified by HHS. If the breach involves less than 500 individuals, an internal log or other documentation of such breaches must be maintained and annually submitted to HHS within 60 days after the end of each Calendar Year;and 4. When a Business Associate, which provides services for the Plan and comes in contact with PHI in connection with those services discovers a breach has occurred, that Business Associate will notify the Plan without unreasonable delay and in no case later than 60 calendar days after discovery of a breach so that the affected Participants may be notified. To the extent possible, the Business Associate should identify each individual whose unsecured PHI has been, or is reasonably believed to have been,breached.
Summary Plan Document