HealthMatters October, Issue 33

Important AlaskaCare Benefit Program Notices

Updated October 2018

This newsletter contains important AlaskaCare benefit program notices of interest to you and your family. Please share this information with your family members. Some of the notices in this newsletter are required by law and other notices contain helpful information. These notices are updated from time to time and some of the federal notices are updated each year. Be sure you are reviewing the most updated version of these important notices.

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Nondiscrimination in Health Care/Elimination of Conflict of Interest

In accordance with the Affordable Care Act, to the extent an item or service is a covered benefit under the Plan, and consistent with reasonable medical management techniques with respect to the frequency, method, treatment, or setting for an item or service, the Plan will not discriminate with respect to participation under the Plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable state law. In this context, discrimination means treating a provider differently based solely on the type of the provider’s license or certification. The Plan is not required to contract with any health care provider willing to abide by the terms and conditions for participation established by the Plan. The Plan is permitted to establish varying reimbursement rates based on quality or performance measures. Additionally, to ensure that the persons involved with adjudicating claims and appeals (such as claim adjudicators and medical experts) act independently and impartially on decisions related to those persons employment status (such as decisions related to hiring, compensation, promotion, termination or retention), will not be made based on whether that person is likely to support a denial of benefits.

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Important Reminder Provide the Plan with the Taxpayer Identification Number or Social Security Number of Each Enrollee in a Health Plan

Employers are required by law to collect the taxpayer identification number (TIN) or social security number (SSN) of each medical plan participant and provide that number on reports that will be provided to the IRS each year. Employers are required to make at least two consecutive attempts to gather missing TINs/SSNs.

If a dependent does not yet have a social security number, visit socialsecurity.gov/online/ss-5.pdf to complete a request form. Applying for a social security number is FREE.

The SSN will also be used to help fulfill mandatory reporting requirements to the Centers for Medicare and Medicaid (CMS) for the purposes of permitting Medicare to coordinate benefits for individuals enrolled in both an employer-sponsored medical plan and Medicare.

If you have not yet provided the social security number (or other TIN) for each of your dependents that you have enrolled in the health plan, please contact the concierge at (855) 784-8646.

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Notice of HIPAA Privacy Practices – AlaskaCare Health Plans

Purpose of This Notice

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

This Notice is required by law.

The AlaskaCare self-funded group health plan, including the State of Alaska Active Employee Plan, the Defined Benefit (DB) Retiree Plan, and the Defined Contribution (DCR) Retiree Plan (which may include health, dental, vision, employee assistance, wellness, medical flexible spending accounts, COBRA administration, or other coverage affecting any structure of the body as those benefits may be offered from time to time) (hereafter referred to as the “Plan”), is required by law to take reasonable steps to maintain the privacy of your personally identifiable health information (called Protected Health Information or PHI) and to inform you about the Plan’s legal duties and privacy practices with respect to Protected Health Information including:

  1. The Plan’s uses and disclosures of PHI,
  2. Your rights to privacy with respect to your PHI,
  3. The Plan’s duties with respect to your PHI,
  4. Your right to file a complaint with the Plan and with the Secretary of the U.S. Department of Health and Human Services (HHS),
  5. The person or office you should contact for further information about the Plan’s privacy practices, and
  6. To notify affected individuals following a breach of unsecured Protected Health Information.

PHI use and disclosure by the Plan is regulated by the Health Insurance Portability and Accountability Act (HIPAA). You may find these rules in Section 45 of the Code of Federal Regulations, Parts 160 and 164. The regulations will supersede this Notice if there is any discrepancy between the information in this Notice and the regulations. The Plan will abide by the terms of the Notice currently in effect. The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all PHI it maintains.

You may receive a Privacy Notice from a variety of the insured group health benefit plans offered by the State of Alaska. Each of these notices will describe your rights as it pertains to that plan and in compliance with the Federal regulation, HIPAA. This Privacy Notice, however, pertains to your Protected Health Information related to the AlaskaCare self-funded benefit plan (the “Plan”) and outside companies contracted to help administer Plan benefits, called “Business Associates.”

Effective Date

The effective date of this Notice is October 1, 2019, and this notice replaces notices previously distributed to you.

Privacy Officer

The Plan has designated a Privacy Officer to oversee the administration of privacy by the Plan and to receive complaints. The Privacy Officer may be contacted at:
State of Alaska
Division of Retirement and Benefits
P.O. Box 110203
Juneau, AK 99811-0203
Phone: (907) 465-4460
Email: doa.drb.benefits@alaska.gov.

Your Protected Health Information

The term Protected Health Information (PHI) includes all information related to your past, present or future health condition(s) that individually identifies you or could reasonably be used to identify you and is transferred to another entity or maintained by the Plan in oral, written, electronic, or any other form.

PHI does not include health information contained in employment records held by the State of Alaska in its role as an employer, including but not limited to: health information on disability benefits, life insurance, accidental death and dismemberment insurance, sick leave, Family or Medical Leave (FMLA), drug testing, etc.

When the Plan May Disclose Your PHI

Under the law, the Plan may disclose your PHI without your written authorization in the following cases:

  • At your request. If you request it, the Plan is required to give you access to your PHI in order to inspect it and copy it.
  • As required by an agency of the government. The Secretary of the Department of Health and Human Services may require the disclosure of your PHI to investigate or determine the Plan’s compliance with the privacy regulations.
  • For treatment, payment or health care operations. The Plan and its Business Associates will use your PHI (except psychotherapy notes in certain instances as described below) without your consent, authorization or opportunity to agree or object in order to carry out treatment, payment, or health care operations.
Definitions and Examples of Treatment, Payment, and Health Care Operations
Treatment is health care Treatment is the provision, coordination, or management of health care and related services. It also includes but is not limited to coordination of benefits with a third party and consultations and referrals between one or more of your health care providers.
  • For example: The Plan discloses to a treating specialist the name of your treating primary care physician so the two can confer regarding your treatment plan.
Payment is paying claims for health care and related activities Payment includes but is not limited to making payment for the provision of health care, determination of eligibility, claims management, and utilization review activities such as the assessment of medical necessity and appropriateness of care.
  • For example: The Plan tells your doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.
Health Care Operations keep the Plan operating soundly. Health care operations includes but is not limited to quality assessment and improvement, patient safety activities, business planning and development, reviewing competence or qualifications of health care professionals, underwriting, enrollment, premium rating, and other insurance activities relating to creating or renewing insurance contracts. It also includes disease management, case management, conducting or arranging for medical review, legal services, and auditing functions including fraud and abuse compliance programs and general administrative activities.
  • For example: The Plan uses information about your medical claims to refer you to a health care management program, to project future benefit costs, or to audit the accuracy of its claims processing functions.

The Plan may disclose PHI to the Plan Sponsor for purposes of treatment, payment, and health care operations in accordance with the Plan amendment. The Plan may disclose PHI to the Plan Sponsor for review of your appeal of a benefit or for other reasons related to the administration of the Plan.

In addition, 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. Summary health information is information that summarizes claims history, claims expenses, or type of claims experienced by individuals for whom the Plan Sponsor has provided health benefits under a group health plan. Identifying information will be deleted from summary health information, in accordance with HIPAA. The Plan may not (and does not) use your genetic information that is PHI for underwriting purposes.

Although the Plan does not routinely obtain psychotherapy notes, an authorization will be required by the Plan before the Plan will use or disclose psychotherapy notes about you. Psychotherapy notes are separately filed notes about your conversations with your mental health professional during a counseling session. They do not include summary information about your mental health treatment. However, the Plan may use and disclose such notes when needed by the Plan to defend itself against litigation filed by you.

The Plan usually will require an authorization form for uses and disclosure of your PHI for sales or marketing purposes if the Plan receives direct or indirect payment from the entity whose product or service is being marketed or sold. You have the right to revoke an authorization at any time.

Use or Disclosure of Your PHI Where You Will Be Given an Opportunity to Agree or Disagree Before the Use or Release

Disclosure of your PHI to family members, other relatives, and your close personal friends without your written consent or authorization is allowed if:

  • The information is directly relevant to the family or friend’s involvement with your care or payment for that care, and
  • You have either agreed to the disclosure or have been given an opportunity to object and have not objected.

Under this Plan your PHI may automatically be disclosed internally within the State of Alaska’s Department of Administration. For example, in the event the Plan is notified of a condition that may initiate a short-term disability benefit, the Plan may automatically communicate this information to the Disability Coordinator to allow the processing of appropriate paperwork.

Note that PHI obtained by the Plan Sponsor’s employees through Plan administration activities will NOT be used for employment related decisions.

Use or Disclosure of Your PHI Where Consent, Authorization or Opportunity to Object Is Not Required

In general, the Plan does not need your written authorization to release your PHI if required by law or for public health and safety purposes. The Plan and its Business Associates are allowed to use and disclose your PHI without your written authorization under the following circumstances:

  1. When required by law.
  2. When permitted for purposes of public health activities. This includes reporting product defects, permitting product recalls and conducting post-marketing surveillance. PHI may also be used or disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if authorized by law.
  3. To a school about an individual who is a student or prospective student of the school, if the Protected Health Information that is disclosed is limited to proof of immunization and the school is required by State or other law to have such proof of immunization prior to admitting the individual.
  4. When authorized by law to report information about abuse, neglect, or domestic violence to public authorities if a reasonable belief exists that you may be a victim of abuse, neglect, or domestic violence. In such case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm.
  5. To a public health oversight agency for oversight activities authorized by law. These activities include civil, administrative or criminal investigations, inspections, licensure or disciplinary actions (for example, to investigate complaints against providers), and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud).
  6. When required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request, provided certain conditions are met.
  7. When required for law enforcement health purposes (for example, to report certain types of wounds).
  8. For law enforcement purposes if the law enforcement official represents that the information is not intended to be used against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to obtain the individual’s agreement, and the Plan in its best judgment determines that disclosure is in the best interest of the individual.
  9. When required to be given to a coroner or medical examiner to identify a deceased person, determine a cause of death, or other authorized duties.
  10. When required to be given to funeral directors to carry out their duties with respect to the decedent or for use and disclosures for cadaveric organ, eye, or tissue donation purposes.
  11. For research, subject to certain conditions.
  12. When, consistent with applicable law and standards of ethical conduct, the Plan in good faith believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
  13. When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.
  14. When required, for specialized government functions, to military authorities under certain circumstances, or to authorized Federal officials for lawful intelligence, counterintelligence and other national security activities

Any other Plan uses and disclosures not described in this Notice will be made only if you provide the Plan with written authorization, subject to your right to revoke your authorization, and information used and disclosed will be made in compliance with the minimum necessary standards of the privacy regulations.

Your Individual Privacy Rights

You May Request Restrictions on PHI Uses and Disclosures You may request the Plan to restrict the uses and disclosures of your PHI:

  • To carry out treatment, payment, or health care operations; or
  • To family members, relatives, friends, or other persons identified by you who are involved in your care.

The Plan, however, is not required to agree to your request if the Plan Administrator or Privacy Officer determines it to be unreasonable--for example, if it would interfere with the Plan’s ability to pay a claim.

You May Inspect and Copy Your PHI

You have the right to inspect and obtain a copy (in hard copy or electronic form) of your PHI (except psychotherapy notes and information compiled in reasonable contemplation of an administrative action or proceeding) contained in a “Designated Record Set,” for as long as the Plan maintains the PHI.

A Designated Record Set includes your medical records and billing records that are maintained by or the Plan. Records include enrollment, payment, billing, claims adjudication, and case or medical management record systems maintained, or other information used by or for the Plan to make decisions about you.

You or your personal representative will be required to complete a form to request access to the PHI in your Designated Record Set. Requests for access to your PHI should be made to the Plan’s Privacy Officer at their address listed on the first page of this Notice. The Plan reserves the right to charge a reasonable cost-based fee for creating or copying the PHI or preparing a summary of your PHI.

You Have the Right to Amend Your PHI

You or your Personal Representative have the right to request that the Plan amend your PHI or a record about you in a designated record set for as long as the PHI is maintained in the designated record set. You should make your request to amend PHI to the Privacy Officer at their address listed on the first page of this Notice.

You Have the Right to Receive an Accounting of the Plan’s PHI Disclosures

At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your PHI during the six years (or shorter period if requested) before the date of your request. The Plan will not provide you with an accounting of disclosures related to treatment, payment, health care operations, or disclosures made to you or authorized by you in writing. If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, costbased fee for each subsequent accounting.

You Have the Right to Request that PHI be Transmitted to You Confidentially

The Plan will permit and accommodate your reasonable request to have PHI sent to you by alternative means or to an alternative location (such as mailing PHI to a different address or allowing you to personally pick up the PHI that would otherwise be mailed), if you provide a written request to the Plan that the disclosure of PHI to your usual location could endanger you. If you believe you have this situation, you should contact the Plan’s Privacy Officer to discuss your request for confidential PHI transmission.

You Have the Right to Receive a Paper or Electronic Copy of This Notice Upon Request

To obtain a paper or electronic copy of this Notice, contact the Plan’s Privacy Officer at their address listed on the first page of this Notice.

Breach Notification

If a breach of your unsecured Protected Health Information occurs, the Plan will notify you.

Your Personal Representative

You may exercise your rights to your Protected Health Information (PHI) by designating a person to act as your Personal Representative. Your Personal Representative will generally be required to produce evidence (proof) of the authority to act on your behalf before the Personal Representative will be given access to your PHI or be allowed to take any action for you.

Under this Plan, proof of such authority will include a completed and signed Authorization for the Use and/or Disclosure of Protected Health Information form (ben043).

This Plan will NOT automatically recognize your spouse as your Personal Representative and vice versa.

In order for your legal spouse to be your Personal Representative, you must complete and submit the Authorization for the Use and/or Disclosure of Protected Health Information form (ben043)to the Division. The form is available on the Division’s website, Alaska. gov/drb/pdf/forms/ben043.pdf.

You may also present the Division with a copy of a notarized Health Care Power of Attorney form allowing one spouse to make decisions about the other spouse’s health care if they are unable to do so, or a document demonstrating you are the court-appointed conservator or guardian for your spouse.

If you have appointed your spouse as your Personal Representative you can indicate the date the authorization expires. If no expiration date is listed, this authorization will expire two (2) years from the date of signature.

The Plan retains discretion to deny access to your PHI to a Personal Representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect.

The Plan will generally consider a parent or guardian as the Personal Representative of an unemancipated minor (a child generally under age 18) unless the applicable law requires otherwise. Spouses and unemancipated minors may request that the Plan restrict PHI that goes to family members as described above under the section titled “Your Individual Privacy Rights.”

The Plan’s Duties

The Plan is required by law to maintain the privacy of your PHI and to provide you and your eligible dependents with Notice of its legal duties and privacy practices. The Plan is required to comply with the terms of this Notice. However, the Plan reserves the right to change its privacy practices and the terms of this notice and to apply the changes to any PHI maintained by the Plan.

Notice Distribution: The Notice will be provided to each person when he or she initially enrolls for benefits in the Retiree Plan (the Notice is provided in the Plan’s New Enrollment materials). The Notice is also available on the State of Alaska website. The Notice will also be provided upon request. Once every three years, the Plan will notify the individuals then covered by the Plan where to obtain a copy of the Notice. This Plan will satisfy the requirements of the HIPAA regulation by providing the Notice to the named insured (covered employee) of the Plan; however, you are encouraged to share this Notice with other family members covered under the Plan.

Notice Revisions: If a privacy practice of this Plan is changed affecting this Notice, a revised version of this Notice will be provided to you and all participants covered by the Plan at the time of the change. Any revised version of the Notice will be distributed within 60 days of the effective date of a material change to the uses and disclosures of PHI, your individual rights, the duties of the Plan, or other privacy practices stated in this Notice. Because our health plan posts its Notice on its website, we will prominently post the revised Notice on that website by the effective date of the material change to the Notice. We will also provide the revised notice, or information about the material change and how to obtain the revised Notice, in our next annual mailing to individuals covered by the Plan.

Disclosing Only the Minimum Necessary Protected Health Information

When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose, or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations.

Your Right to File a Complaint

If you believe that your privacy rights have been violated, you may file a complaint with the Plan in care of the Plan’s Privacy Officer, at the address listed on the first page of this Notice. Neither your employer nor the Plan will retaliate against you for filing a complaint.

You may also file a complaint (within 180 days of the date you know or should have known about an act or omission) with the Secretary of the U.S. Department of Health and Human Services by contacting their nearest office as listed in your telephone directory or through their website, hhs.gov/ocr/about-us/contact-us/index.html or hhs.gov/ ocr/privacy/hipaa/complaints/index.html, or contact the Privacy Officer for more information about how to file a complaint.

If You Need More Information

If you have any questions regarding this Notice or the subjects addressed in it, you may contact the Plan’s Privacy Officer at the address listed at the beginning of this Notice.

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Notice of Special Enrollment Rights

IMPORTANT: After the open enrollment period is completed (or, if you are a new hire, after your initial enrollment election period is over), generally you will not be allowed to change your benefit elections or add/delete dependents until next year’s open enrollment, unless you have a Special Enrollment Event or a Mid-year Permitted Election Change Event as outlined below:

  • Loss of Other Coverage Event: If you decline enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing towards the other coverage).
  • Marriage, Birth, Adoption Event: If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
  • Medicaid/CHIP Event: You and your eligible dependents may also enroll in this plan if you (or your dependents):
    • have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and you (or your dependents) lose eligibility for that coverage. However, you must request enrollment within 60 days after the Medicaid or CHIP coverage ends.
    • become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment within 60 days after you (or your dependents) are determined to be eligible for such assistance.

To request special enrollment or obtain more information, contact the concierge at (855) 784-8646.

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Women’s Health and Cancer Rights Act of 1998 (WHCRA) Annual Notice Reminder

If you are covered under the AlaskaCare Employee Health Plan, you or your dependents may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient 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 of the mastectomy, including lymphedema.

Plan limits, deductibles, copayments, and coinsurance apply to these benefits. For more information on WHCRA benefits, see the AlaskaCare Employee Health Plan document at AlaskaCare.gov/employee/publications/booklet.html or contact the concierge at (855) 784-8646.

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Availability of Summary of Benefits and Coverage Document(s)

The health benefits that are available to you from the State of Alaska AlaskaCare Employee Health Plan 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. In accordance with law, our employee plan provides you with Summary of Benefits and Coverage (SBC) documents to help you understand and compare medical plan benefits. Each SBC document summarizes and compares essential information including what is covered, what isn’t, what you need to pay for diverse benefits, and where to get answers to questions. The SBC documents are updated when there is a change to the benefits information. To get a free copy of the most current SBC documents for our State of Alaska medical plan options, go to AlaskaCare.gov, or for a paper copy, contact the Division of Retirement and Benefits toll free at (800) 821-2251 or (907) 465-4460 in Juneau.

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COBRA Coverage Reminder

In compliance with a federal law referred to as COBRA Continuation Coverage, this plan offers AlaskaCare members and their covered dependents (known as qualified beneficiaries) the opportunity to elect temporary continuation of their group health coverage when that coverage would otherwise end because of certain events (called qualifying events).

Qualified beneficiaries are entitled to elect COBRA when certain events occur, and, because of the event, coverage of that qualified beneficiary ends (together, the event and the loss of coverage are called a qualifying event). Qualified beneficiaries who elect COBRA Continuation Coverage must pay for it at their own expense. Current defined benefit retirees COBRA rates are available at Alaska.gov/DRB/AlaskaCare/retiree/information/cobraPremiums.html and current active COBRA rates are available at Alaska.gov/DRB/AlaskaCare/employee/information/premiums.html.

Qualifying events may include termination of employment, reduction in hours of work making the employee ineligible for coverage, death of the employee, divorce/legal separation, or a child ceasing to be an eligible dependent child under the terms of the plan, if a loss of coverage results.

In addition to considering COBRA to continue coverage, there may be other coverage options for you and your family. You may want to look for coverage through the Health Care Marketplace at healthcare.gov. In the Marketplace, you could be eligible for a tax credit that lowers your monthly premiums for Marketplace coverage, and you can see what your premium, deductibles, and out-of-pocket costs will be before you decide to enroll. Being eligible for COBRA does not limit your eligibility for Marketplace coverage or for the tax credit. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan) if you request enrollment within 30 days, even if the plan generally does not accept late enrollees. The maximum period of COBRA coverage is usually either 18 months or 36 months, depending on which qualifying event occurred.

To have the chance to elect COBRA coverage after a divorce/ legal separation or a child ceasing to be a dependent under the plan, you and/or a family member must inform the plan in writing of that event no later than 60 days after that event occurs. Notices must be sent via first class mail to:
Division of Retirement and Benefits
P.O. Box 110203
Juneau, AK 99811-0203.

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General Statement of Nondiscrimination

The State of Alaska complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The State of Alaska does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The State of Alaska:

  1. Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  2. Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services related to your AlaskaCare health plan, please contact the Aetna concierge at (855) 784-8646 or through Aetna Navigator. If you believe that the State of Alaska has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, employees can file a grievance with their department’s civil rights coordinator. If you need assistance in finding your department’s coordinator, you can contact the State’s Equal Employment Opportunity Program Coordinator, Camille Brill, at (907) 375-7700. Retirees can contact the Division of Retirement and Benefits at (800) 821-2251 or in Juneau at (907) 465-4460.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf, or phone (800) 868-1019, 800-537-7697 (TDD) or by mail at:
U.S. Department of Health and Human Services
200 Independence Avenue SW
Room 509F, HHH Building,
Washington, DC 20201
Complaint forms are available at hhs.gov/ocr/office/file/index.html.

Attention: Free Language Assistance

This chart displays, in various languages, the phone number to call for free language assistance services for individuals with limited English proficiency. What the below required taglines say is this:

ATTENTION: If you speak [insert language], language assistance services, free of charge, may be available to you. Contact (855) 784-8646 (TTY: (800) 628-3323).

Language Message About Language Assistance
Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-784-8646 (TTY: 1-800-628-3323).
Chinese 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-855-784-8646 (TTY: 1-800-628-3323) 。
Japanese 注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-855-784-8646 (TTY:1-800-628-3323)まで、お電話にてご連絡ください。
French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-784-8646 (ATS : 1-800-628-3323).
ItalianATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-784-8646 (TTY: 1-800-628-3323).
GermanACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-784-8646 (TTY: 1-800-628-3323).
HmongLUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-855-784-8646 (TTY: 1-800-628-3323).
VietnameseCHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-784-8646 (TTY: 1-800-628-3323).
Hindiध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-855-784-8646 (TTY: 1-800-628-3323) पर कॉल करें।
Gujaratiસુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-855-784-8646 (TTY: 1-800-628-3323).
TagalogPAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-784-8646 (TTY: 1-800-628-3323).
Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم
.(رقم هاتف الصم والبكم: 1-3323-628-800) x855-784-8646-1
Korean주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-855-784-8646 (TTY: 1-800-628-3323)번으로 전화해 주십시오.
Thaiเรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-855-784-8646 (TTY: 1-800-628-3323).
RussianВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-784-8646 (телетайп: 1-800-628-3323).
Urdu خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں
1-855-784-8646  (TTY: 1-800-628-3323).
Cambodianប្រយ័ត្ន៖ បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, សេវាជំនួយផ្នែកភាសា ដោយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។ ចូរ ទូរស័ព្ទ 1-855-784-8646 (TTY: 1-800-628-3323)។
Punjabiਧਿਆਨ ਦਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਵਿੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-855-784-8646 (TTY: 1-800-628-3323) 'ਤੇ ਕਾਲ ਕਰੋ।
French Creole (Haitian)ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-855-784-8646 (TTY: 1-800-628-3323).
Laoໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-855-784-8646 (TTY: 1-800-628-3323).
IndonesianPERHATIAN: Jika Anda berbicara dalam Bahasa Indonesia, layanan bantuan bahasa akan tersedia secara gratis. Hubungi 1-855-784-8646 (TTY: 1-800-628-3323).
HawaiianE NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo [hoʻokomo ʻōlelo], loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1-855-784-8646 (TTY: 1-800-628-3323).

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Notice of Privacy Practices – AlaskaCare Health Plans

Notice of Privacy Practices – AlaskaCare Health Plans

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The State of Alaska group health plan including the Employee Health Plan, Retiree Benefit Plan, and Retiree Benefit Plan for DCR Plan Retirees (hereafter referred to as the “Plan”), is required by law to take reasonable steps to maintain the privacy of your personally identifiable health information (called Protected Health Information or PHI) and to inform you about the Plan’s legal duties and privacy practices with respect to Protected Health Information.

Your Individual Privacy Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

You have the right to:

Get a copy of your health and claims records

  • You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct health and claims records

  • You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment, or our operations.
  • We are not required to agree to your request, and we may say “no” if the Privacy Officer determines it to be unreasonable.

Get a list of those with whom we’ve shared information

  • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints.
  • We will not retaliate against you for filing a complaint.

Notify you of a breach

  • If a breach of your unsecured health information occurs, we will notify you.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with your family, close friends, or others involved in payment for your care.
  • Contact you for fundraising efforts.
  • Share information in a disaster relief situation. If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes
  • Sale of your information

Uses and Disclosures Without Authorization

We may use of share your health information without your written permission in certain circumstances:

Help manage the health care treatment you receive

  • We can use your health information and share it with professionals who are treating you.

Example: We disclose to a treating specialist the name of your treating primary care physician so the two can confer regarding your treatment plan.

Run our organization

  • We can use and disclose your information to run our organization and contact you when necessary.
  • We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Example: We use health information about you to develop better services for you.

Pay for your health services

  • We can use and disclose your health information as we pay for your health services.

Example: We tell your doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.

Administer your plan

  • We may disclose your health information to your health plan sponsor for plan administration.

Example: We review information about your medical claims to refer you to a health care management program.

How else can we use or share your health information?

  • We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as helping with product recalls or reporting adverse reactions to medications.

For research

  • We can use or share your information for health research, subject to certian condtions.

To a school for required proof of immunizations when required by law

  • We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

  • We can share health information about you with organ procurement organizations.
  • We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

To comply with workers’ compensation programs for public health oversight activitis authorized by law

  • We can share health information with public health agencies for oversight of benefit programs (for example, to investigate Medicare fraud).

For specialized government functions

  • We can share your information for special government functions such as military, national security, and presidential protective services.

Respond to lawsuits and legal actions

  • We can share health information about you in response to a court or administrative order, or in response to a subpoena.

For law enforcement purposes

  • We can share health information about you to law enforcement officials in urgent circumstances such as for identifying a suspect or victim of a crime.

When Disclosure Requires Your Authorization

Generally, we will require that you sign a valid authorization form in order to use or disclose your health information other than:

  • When you request your own PHI
  • A government agency requires it, or
  • The plan uses it for treatment, payment or health care operation.

You have the right to revoke an authorization.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the legal duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:
hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

This Notice of Privacy Practices applies to the following organizations:

This Notice of Privacy Practices applies to the benefits in the State of Alaska Employee Health Plan, the State of Alaska Retiree Benefit Plan, and the State of Alaska Retiree Benefit Plan for DCR Plan Retirees that pay for the cost of, or provide medical benefits (which may include health, dental, vision, employee assistance, wellness, medical flexible spending accounts, COBRA administration, or other coverage affecting any structure of the body as those benefits may be offered from time to time). It does not apply to other benefits provided by the State of Alaska, such as life insurance, disability benefits, or accidental death and dismemberment insurance. If you receive health benefits through an insurance company through the State of Alaska you may also receive a notice from the insurer. That notice will describe how the insurer will use your health information and provide your rights.

The effective date of this Privacy Notice is January 1, 2019 and this notice replaces notices previously distributed to you.

For questions, contact Steve Ramos, HIPAA Privacy Officer, at (907) 465-4460 or doa.drb.benefits@alaska.gov.

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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 are eligible for health coverage from your employer, the State of Alaska may have a premium assistance program that can help pay for coverage, using funds from the Medicaid or CHIP programs. If you or your children are not eligible for Medicaid or CHIP, you will not 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 healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in the State of Alaska, the Alaska Health Insurance Premium Payment Program at (866) 251-4861 or by email at CustomerService@MyAKHIPP.com to find out if premium assistance is available.

Additional Resources:

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 programs, contact your state Medicaid or CHIP office, dial (877) KIDS-NOW or visit insurekidsnow.gov to find out how to apply. If you qualify, ask your state Medicaid 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 are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at askebsa.dol.gov or call (866) 444-EBSA(3272). You may also change your election if you have a change in status or another applicable event. Please see the AlaskaCare Employee Health Plan document for additional information.

If you live in one of the following states, you may be eligible for assistance paying your employer health premiums. The following list of states is current as of July 31, 2019 . Contact your STATE for more information.

U.S. Department of Labor
Employee Benefits Security Administration
Website: dol.gov/ebsa
(866) 444-EBSA (3272).

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services
Website: cms.hhs.gov
(877) 267-2323, Menu Option 4, Ext. 61565.

OMB Control Number 1210-0137 (Expires 12/31/2019).

ALABAMA - Medicaid FLORIDA - Medicaid
Website: myalhipp.com
Phone: 1-855-692-5447
Website: flmedicaidtplrecovery.com/hipp
Phone: 1-877-357-3268
ALASKA - Medicaid GEORGIA - Medicaid
The AK Health Insurance Premium Payment Program Website: myakhipp.com
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
Website: dch.georgia.gov/medicaid
Click on Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507
ARKANSAS - Medicaid INDIANA - Medicaid
Website: myarhipp.com
Phone: 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64 Website: in.gov/fssa/hip
Phone: 1-877-438-4479
All other Medicaid Website: indianamedicaid.com
Phone: 1-800-403-0864
COLORADO - Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+) IOWA - Medicaid
Health First Colorado Website: healthfirstcolorado.com
Health First Colorado Member Contact Center: 1-800-221-3943 | State Relay 711
CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus
CHP+ Customer Service: 1-800-359-1991 | State Relay 711

Website: dhs.iowa.gov/hawk-i
Phone: 1-800-257-8563
KANSAS - Medicaid NEW HAMPSHIRE - Medicaid
Website: kdheks.gov/hcf
Phone: 1-785-296-3512
Website: dhhs.nh.gov/ombp/nhhpp
Phone: 603-271-5218
Hotline: NH Medicaid Service Center at 1-888-901- 4999
KENTUCKY - Medicaid NEW JERSEY - Medicaid and CHIP
Website: chfs.ky.gov
Phone: 1-800-635-2570
Medicaid Website: state.nj.us/humanservices/dmahs/ clients/medicaid
Medicaid Phone: 609-631-2392
CHIP Website: njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
LOUISIANA - Medicaid NEW YORK - Medicaid
Website: dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
Website: health.ny.gov/health_care/medicaid
Phone: 1-800-541-2831
MAINE - Medicaid NORTH CAROLINA - Medicaid
Website: maine.gov/dhhs/ofi/public- assistance/index.html
Phone: 1-800-442-6003 | TTY: Maine relay 711
Website: dma.ncdhhs.gov
Phone: 919-855-4100
MASSACHUSETTS - Medicaid and CHIP NORTH DAKOTA - Medicaid
Website: mass.gov/eohhs/gov/departments/ masshealth
Phone: 1-800-862-4840
Website: nd.gov/dhs/services/medicalserv/medicaid Phone: 1-844-854-4825
MINNESOTA - Medicaid OKLAHOMA - Medicaid and CHIP
Website: mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services
Phone: 1-800-657-3739
Website: insureoklahoma.org
Phone: 1-888-365-3742
MISSOURI - Medicaid OREGON - Medicaid
Website: dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
Website: healthcare.oregon.gov/Pages/index.aspx
Phone: 1-800-699-9075
MONTANA - Medicaid PENNSYLVANIA - Medicaid
Website: dphhs.mt.gov/MontanaHealthcarePrograms/HI
Phone: 1-800-694-3084
Website: dhs.pa.gov/provider/medicalassistance/he althinsurancepremiumpaymenthippprogram/index.htm
Phone: 1-800-692-7462
NEBRASKA - Medicaid RHODE ISLAND - Medicaid
Website: ACCESSNebraska.ne.gov
Phone: (855) 632-7633 | Lincoln: (402) 473-7000 | Omaha: (402) 595-1178
Website: eohhs.ri.gov
Phone: 855-697-4347
NEVADA - Medicaid SOUTH CAROLINA - Medicaid
Medicaid Website: dhcfp.nv.gov
Medicaid Phone: 1-800-992-0900
Website: scdhhs.gov
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid WASHINGTON - Medicaid
Website: dss.sd.gov Phone: 1-888-828-0059 Website:hca.wa.gov/health-care-services-supports/program-administration/premium-payment-program
Phone: 1-800-562-3022 ext. 15473
TEXAS - Medicaid WEST VIRGINIA - Medicaid
Website: gethipptexas.com
Phone: 1-800-440-0493
Website: mywvhipp.com
Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
UTAH - Medicaid and CHIP WISCONSIN - Medicaid and CHIP
Medicaid Website: medicaid.utah.gov
CHIP Website: health.utah.gov/chip
Phone: 1-877-543-7669
Website: dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002
VERMONT - Medicaid WYOMING - Medicaid
Website: greenmountaincare.org
Phone: 1-800-250-8427
Website: wyequalitycare.acs-inc.com
Phone: 307-777-7531
VIRGINIA - Medicaid and CHIP
Medicaid Website: coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Phone: 1-855-242-8282

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Patient Protection Rights of the Affordable Care Act

Designation of a Primary Care Provider (PCP):

The medical plans offered by the State of Alaska do not require the selection or designation of a primary care provider (PCP). You have the ability to visit any in-network (or non-network) health care provider; however, payment by the Plan may be less for the use of a non-network provider. To locate an in-network provider, visit Aetna’s provider directory, DocFind®, at aetna.com/docfind/custom/alaskacare.

Direct Access to OB/GYN Providers:

You do not need prior authorization (pre-approval) from the State of Alaska or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological (OB/GYN) care from an in-network health care professional who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Aetna’s customer service/provider locator at (855) 784-8646.

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