instruction sheet for: ucop 2016 health benefits open

INSTRUCTION SHEET FOR:
UCOP 2016 HEALTH BENEFITS OPEN ENROLLMENT FORM
Purpose: The 2016 Health Benefits Open Enrollment period runs from October 29 – November 24, 2015. As
part of UCOP’s transition to UCPath, during this year’s Open Enrollment UCOP employees will use this form to
elect 2016 health and welfare benefits (the ability to elect 2016 benefits will not be available via At Your Service
Online). If you do not intend to make any changes to your benefits, you do not need to submit a form, unless you
would like to enroll or continue your participation in the Flexible Spending Account (FSA). If you do not make any
changes to your benefits, your current 2015 elections will carry over to 2016 (with the exception of the FSA, which
requires enrollment every year). If you wish to reenroll in the FSA, please complete and submit this form on or
before 5:00 p.m. (PST) November 24, 2015.
This form applies only to this year. In future years, you will make your benefits elections online using UCPath.
You may view your current benefits via At Your Service Online at https://atyourserviceonline.ucop.edu/.
Instructions: Start by saving your blank form to your computer desktop. This will allow you to upload it to the
UCPath system once you've completed it.
Section 1: Enter your personal information (your employee ID may be found in AYSO). You may type your
information directly into the form.
Section 2: Starting with yourself, list any dependents and enter their personal details. Then, check the box of the
benefit plan in which your dependents will be enrolled. You may only enroll family members into plans in which
you are enrolled. Please note: The Affordable Care Act (ACA) requires employers to make reasonable efforts to
obtain Social Security numbers for employees, spouses/domestic partners, and children.
Section 3: Select your 2016 benefits by checking the box for the appropriate plan.
a. With the exception of TIP, Health FSA, and DepFSA, if you leave a plan section blank it is the same as
checking the "No change" box and your current 2015 election will carry over to 2016.
b. You are eligible for HSA only if you elect the medical Blue Shield Health Savings Plan.
c. If you elect the HSA, you are not eligible to participate in the Health FSA.
Section 4: When you have completed your form, sign it by typing your first and last name in the signature
area, and date it. It is recommended you save a copy for your records.
Submitting your form: You have three ways to submit your form:
1. Via a secure personalized link: In late October, you will receive an email in your UCOP email account.
The email will include a personalized link for you to use to submit your form. Because this is a
personalized link, for your protection, do not forward this email or link to anyone.
2. By fax to the UCPath Center at: (951) 697-6839,
3. By mail to the UCPath Center at:
University of California - UCPath Center
14350-1 Meridian Parkway
Riverside, CA 92518
In mid-December, you will receive an email from the UCPath Center confirming your benefit elections (even
if you don’t make changes during Open Enrollment).
Deadline: Forms must be submitted on or before 5 p.m. (PST) November 24, 2015. If you submit a form
during Open Enrollment and want to make additional changes, you will need to submit another fully completed
form. If you submit multiple forms, the form with the most recent date will be processed as your final elections.
Disclaimers/Notifications: By typing your first and last name in the signature area, you agree to use electronic
signature to authorize your benefit elections.
If you have questions you may contact the UCPath Center at:
(855) 982-7284 or (855) 9-UCPath
Monday - Friday: 8 a.m. - 5 p.m.
Form No: FR.060
pg. i of viii
Last Revised: 10/2015
UCOP 2016 HEALTH BENEFITS OPEN ENROLLMENT FORM
Note: Adobe Reader is required to properly
view, complete, print, and save this document.
Instructions: Visit At Your Service Online (AYSO) to review your current benefit plan enrollments. Then, if you want to make
changes, complete, sign and submit this form on or before 5:00 p.m. (PST) November 24, 2015, preferably via the secure
personalized link you received by email. Required fields outlined in red must be completed in order for your form to be processed.
1. PERSONAL INFORMATION Enter your personal information. Your Employee ID may be found in At Your Service (AYSO).
Name (Last, First, Middle Initial)
Employee ID
Phone Number
Email Address
2. DEPENDENTS Starting with yourself, list each dependent and their personal details. Then, check the box of each benefit in
which your dependents will be enrolled. You may only enroll family members into plans in which you are enrolled. If you have
more than six dependents, complete a second form and fill out sections 1,2, & 4. The Affordable Care Act (ACA) requires
employers to make reasonable efforts to obtain Social Security numbers for employees, spouses/domestic partners, and children.
Birthdate
Name (Last, First, Middle Initial)
Your Name Listed First
(mm/dd/yyyy)
Gender Relationship
1
Code
(M/F)
Self
1
2
3
Relationship Codes: S=Spouse
R=Registered Domestic Partner
3
P=Stepchild
K=Domestic Partner’s child or grandchild
Employee Spouse/Dom Social Security
Number
Medical Dental Vision
Tax2
Partner Tax2
Dependent? Dependent?
(Yes/No)
(Yes/No)
N=Not Registered Domestic Partner
G=Grandchild
W=Legal Ward
Legal
C= Child (biological or adopted)
2
O= Overage disabled child
Dependent eligibility requirements may be found on page 12 of the Complete Guide to Your UC Health Benefits.
If your domestic partnership is registered and you are considered the child’s stepparent under state law, enter Code “P” for Stepchild. Otherwise, enter code “K”.
3. BENEFIT ELECTIONS Select your 2016 plans by checking the box for each plan. With the exception of TIP, Health FSA, and
DepFSA, if you leave a plan section blank it is the same as checking the "No change" box and your current 2015 election
will carry over to 2016.
TIP (Tax Savings on Insurance Premiums)
LEGAL PLAN
Your medical premium deductions will automatically default to occur on a
pre- tax, salary reduction basis. If you wish to decline and have post-tax
deductions instead, check the box and place your initials below.
Decline/Opt Out of TIP
ARAG Legal Plan
No change
Decline plan
FLEXIBLE SPENDING ACCOUNTS
If you elect the HSA you are not eligible to participate in the Health FSA.
Initials
Health FSA Contribution:
To learn more, you may go to the TIP summary plan description.
MEDICAL PLAN
Annual
Monthly
Biweekly
Annual
Monthly
Biweekly
DepCare FSA Contribution:
Blue Shield Health Savings Plan
UC Care
Health Net Blue & Gold HMO
Core
Kaiser Permanente
Decline plan
Western Health Advantage (WHA)
No change
2016 Annual FSA Contribution Limits:
Health FSA: $2,550
DepCare FSA: $5,000
Clear Medical, Health FSA, & HSA
BLUE SHIELD HEALTH SAVINGS ACCOUNT (HSA)
You are eligible for HSA only if you elect the medical Blue Shield Health Savings Plan.
DENTAL PLAN
HSA Contribution:
Delta Dental PPO
Decline plan
DeltaCare® USA DHMO
No change
Annual
No change
VISION PLAN
VSP
Decline plan
No change
Monthly
Biweekly
2016 Annual HSA Contribution Limits:
Employee
UC Contribution
Single Coverage: $2,850
$500
Family Coverage: $5,750
$1,000
Age 55 or older:
$1,000 additional allowed
4. SIGNATURE By typing my first and last name in the box below, I agree to use electronic signature to authorize my benefit elections.
Signature
Date
Save Form
Print Form
It is recommended you save a copy of this form for your records.
Form No: FR.060
pg. ii of viii
Last Revised: 10/2015
Participation Terms and Conditions
to cover your contributions toward the monthly costs (if
any) for the plans you have chosen for yourself and
your eligible family members. You are also authorizing
UC to transmit your enrollment demographic data to the
plans in which you are enrolled.
Your Social Security number, and that of your
enrolled family members, is required for purposes
of benefit plan administration, for financial
reporting, to verify your identity,and for legally
required reporting purposes all in compliance with
federal and state laws.
If you are are confirmed as eligible for participation in
UC-sponsored plans, you are subject to the following
terms and conditions:
1. With the exception of benefits provided or
administered by Blue Shield of California and
Optum Behavioral Health, UC-sponsored medical
plans require resolution of disputes through
arbitration. With regard to each plan IT IS
UNDERSTOOD THAT ANY DISPUTE AS TO
MEDICAL MALPRACTICE – THAT IS, AS TO
WHETHER ANY MEDICAL SERVICES
RENDERED UNDER THE CONTRACT WERE
UNNECESSARY OR UNAUTHORIZED OR
WERE IMPROPERLY, NEGLIGENTLY OR
INCOMPETENTLY RENDERED – WILL BE
DETERMINED BY SUBMISSION TO
ARBITRATION AS PROVIDED BY CALIFORNIA
LAW AND NOT BY A LAWSUIT OR RESORT TO
COURT PROCESS, EXCEPT AS CALIFORNIA
LAW PROVIDES FOR JUDICIAL REVIEW OF
ARBITRATION PROCEEDINGS. BOTH
PARTIES TO THE CONTRACT, BY ENTERING
INTO IT, ARE GIVING UP THEIR
CONSTITUTIONAL RIGHT TO HAVE ANY
SUCH DISPUTE DECIDED IN A COURT OF
LAW BEFORE A JURY AND INSTEAD ARE
ACCEPTING THE USE OF ARBITRATION. For
more information about each plan's arbitration
provision please see the appropriate plan booklet
or call the plan.
2.
3.
UC and UC health and welfare plan vendors comply
with federal/state regulations related to the privacy of
personal/confidential information including the Health
Insurance Portability and Accountability Act of 1996
(HIPAA) as applicable. To fulfill their contracted
responsibilities and services health plans and
associated service vendors may share UC member
health information between and among each other
within the limits established by HIPAA and federal/state
regulations for purposes of health care operations,
payment, and treatment. A member's requested
restriction on the sharing of specified protected health
information for health care operations, payment, and
treatment will be honored as required by HIPAA.
By making an election with your written or electronic
signature you are authorizing the University to take
deductions from your earnings
4.
You are subject to all terms and conditions of the UCsponsored plans in which you are enrolled as stated in
the plan booklets and the University of California Group
Insurance Regulations.
5.
By enrolling individuals as your family members you are
certifying that those individuals are eligible for coverage
based on the definitions and rules specified in the
University of California Group Insurance Regulations and
described in UC health and welfare plan eligibility
publications. You are also certifying under penalty of
perjury that all the information you provide regarding the
individuals you enroll is true to the best of your
knowledge.
6.
If you enroll individuals as your family members you must
provide, upon request, documentation verifying that
those individuals are eligible for coverage. The carrier
may also require documentation verifying eligibility.
Verification documentation includes, but is not limited to,
marriage or birth certificates, domestic partner
verification, adoption papers, tax records and the like.
7.
If your enrolled family member loses eligibility for UCsponsored coverage (for example because of divorce or
loss of eligible child status) you must notify UC by deenrolling that individual. If you wish to make a permitted
change in your health or flexible spending account
coverage you must notify UC within 31 days of the
eligibility loss event; for purposes of COBRA, eligibility
notice must be provided to UC within 60 days of the
family member's loss of coverage. However, regardless
of the timing of notice to UC, coverage for the ineligible
family member will end on the last day of the month in
which the eligibility loss event occurs (subject to any
continued coverage option available and elected.)
8.
Making false statements about satisfying eligibility
criteria, failing to timely notify the University of a
family member's loss of eligibility, or failing to provide
verification documentation when requested may lead
to de-enrollment of the affected family members.
Employees/retirees may also be subject to
disciplinary action and de-enrollment from health
benefits and may be responsible for any UC-paid
premiums due to misuse of plan.
9.
Under current state and federal tax laws, the value of
the contribution UC makes toward the cost of health
coverage provided to domestic partners and certain
other family members who are not "your dependents"
under state and federal tax rules may be considered
imputed income that will be subject to income taxes,
FICA (Social Security and Medicare), and any other
required payroll taxes. (Coverage provided to California
registered domestic partners is not subject to imputed
income for California state tax purposes.)
(employees)/monthly Retirement Plan income (retirees)
Form No: FR.060
pg. iii of viii
Last Revised: 10/2015
10. If you specifically ask UC representatives to intercede
on your behalf with your insurance plan, University
representatives will request the minimum necessary
protected health information required to assist you with
your problem. If more protected health information is
needed to solve your problem in compliance with state
laws and federal privacy laws (including HIPAA), you
may be required to sign an authorization allowing UC to
provide the health plan with relevant protected health
information or authorizing the health plan to release
such information to the University representative.
11. Actions you take during Open Enrollment will be effective
the following January 1unless otherwise stated - provided
all electronic and form transactions have been completed
properly and submitted timely.
IMPORTANT NOTICES
HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT OF 1996 (HIPAA)
NOTIFICATION FOR MEDICAL PROGRAM
ELIGIBILITY
If you are declining enrollment for yourself or your eligible
family members because of other medical insurance or
group medical plan coverage, you may be able to enroll
yourself and your eligible family members* in a UCsponsored medical plan if you or your family members lose
eligibility for that other coverage (or if the employer stops
contributing toward the other coverage for you or your family
members.) You must request enrollment within 31 days after
you or your family member's other medical coverage ends
(or after the employer stops contributing toward the other
coverage).
In addition, if you have a newly eligible family member as a
result of marriage or domestic partnership, birth, adoption, or
placement for adoption, you may be eligible to enroll your
newly eligible family member. If you are an employee you
may be eligible to enroll yourself, in addition to your eligible
family member(s). You must request enrollment within 31
days after the marriage or partnership, birth, adoption, or
placement for adoption.
If you decline enrollment for yourself or for an eligible family
member because of coverage under Medicaid (in California,
Medi-Cal) or under a state children's health insurance
program (CHIP) you may be able to enroll yourself and your
eligible family members in a UC-sponsored plan if you or your
family members lose eligibility for that coverage. You must
request enrollment within 60 days after your coverage or your
family members' coverage ends under Medicaid or CHIP.
Also, if you are eligible for health coverage from UC but
cannot afford the premiums, some states have premium
assistance programs that can help pay for coverage. For
details, contact the U.S. Department of Health and Human
Services, Centers for Medicare and Medicaid Services at
Form No: FR.060
pg. iv of viii
www.cms.gov or 1-877-267-2323 ext. 61565.
IF YOU DO NOT ENROLL YOURSELF AND/OR YOUR
FAMILY MEMBER(S) IN MEDICAL COVERAGE WITHIN
THE 31 DAYS WHEN FIRST ELIGIBLE, WITHIN A
SPECIAL ENROLLMENT PERIOD DESCRIBED ABOVE,
OR WITHIN AN OPEN ENROLLMENT PERIOD, YOU MAY
BE ELIGIBLE TO ENROLL AT A LATER DATE. However,
even if eligible, each affected individual will need to complete
a waiting period of 90 consecutive calendar days before
medical coverage becomes effective and employee
premiums may need to be paid on an after-tax basis (retiree
premiums are always paid after-tax). Otherwise, you/they
can enroll during the next Open Enrollment Period.
To request special enrollment or obtain more information,
employees should contact their local Benefits Office and
retirees should call the UC Retirement Administration
Service Center (1-800-888-8267).
Note: If you are enrolled in a UC medical plan you may be able
to change medical plans if:
you acquire a newly eligible family member; or
your eligible family member loses other coverage.
In either case you must request enrollment within 31 days of
the occurrence.
* To be eligible for plan membership, you and your family
members must meet all UC employee or retiree enrollment
and eligibility require-ments. As a condition of coverage,
all plan members are subject to eligibility verification by
the university and/or insurance carriers, as described in
the participation terms and conditions.
By authority of the Regents, University of California Human
Resources located in Oakland administers all benefit plans in
accordance with applicable plan documents and regulations,
custodial agreements, University of California Group
Insurance Regulations, group insurance contracts, and state
and federal laws. No person is authorized to provide benefits
information not contained in these source documents and
information not contained in these source documents cannot
be relied upon as having been authorized by the Regents.
Source documents are available for inspection upon request
(1-800-888-8267). What is written here does not constitute a
guarantee of plan coverage or benefits--particular rules and
eligibility requirements must be met before benefits can be
received.
The University of California intends to continue the benefits
described here indefinitely; however the benefits of all
employees, retirees, and plan beneficiaries are subject to
change or termination at the time of contract renewal or at
any other time by the University or other governing
authorities. The University also reserves the right to determine
new premiums, employer contributions, and monthly costs at
any time. Health and welfare benefits are not accrued or
vested benefit entitlements. UC's contribution toward the
monthly cost of the coverage is determined by UC and may
change or stop altogether and may be affected by the state of
California's annual budget appropriation. If you belong to an
exclusively represented bargaining unit some of your benefits
Last Revised: 10/2015
may
differ from the ones described here. For more information
employees should contact their Human Resources
Office and retirees should call the UC Retirement
Administration Service Center (1-800-888-8267).
The privacy protections described in this notice reflect the
requirements of federal regulations issued under the
Health Insurance Portability and Accountability Act (HIPAA).
They require the Self-Funded Plans to:
In conformance with applicable law and University policy, the
University is an affirmative action/equal opportunity employer.
Please send inquiries regarding the University's affirmative
action and equal opportunity policies for staff to System wide
AA/EEO Policy Coordinator, University of California Office of
the President, 1111 Franklin Street, 5th Floor, Oakland CA
94607 and for faculty to the Office of Academic Personnel,
University of California Office of the President, 1111 Franklin
Street, Oakland CA 94607.
-
-
How the Self-Funded Plans Will Use and
Disclose Protected Health Information
About You
The following sections describe different ways that a
Self-Funded Plan might use and disclose your PHI. Not
every use or disclosure will be listed. All of the ways that
a Self-Funded Plan is permitted to use and disclose PHI,
however, will fall within one of the categories. Use and
disclosure of some PHI, such as certain drug and
alcohol information, HIV information, and mental health
information, is further restricted.
UNIVERSITY OF CALIFORNIA HEALTH
CARE PLAN NOTICE OF PRIVACY
PRACTICES - SELF-FUNDED 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 University offers various healthcare options to its
employees and retirees and their eligible family members
through the UC Healthcare Plan. Several options are selffunded group health plans for which the University acts as its
own insurer and directly pays the claims. This notice
describes the privacy practices that the University has
established for these options which are referred to as the
"Self-Funded Plans." They are managed for the University by
business associates, which are third party administrators that
interact with the healthcare providers and handle members'
claims.
The other healthcare options offered under the UC
Healthcare Plan are fully insured group health plans for which
the insurance company or health maintenance organization
(HMO) assumes the financial risk of paying for the plan
benefits. The notices of privacy practices for those plans are
available directly from the insurance carrier or HMO. Please
go to http://ucnet.universityofcalifornia.edu/compensationand-benefits/ for a current list of options.
UC'S Commitment
The University is committed to protecting the privacy of your
protected health information or PHI. PHI refers to health
information that a Self-Funded Plan creates or receives that
relates to your physical or mental health, your healthcare, or
payment for your healthcare. In most cases, your PHI is
maintained by the business associate that serves as the third
party administrator for the Self-Funded Plan in which you
participate, but the University may also hold health-related
information. Generally, the University-held information is
limited to enrollment data, but in limited instances, it may
include information you provide to designated UC staff to help
with coordination of benefits, or resolving complaints.
Form No: FR.060
-
Comply with HIPAA privacy standards and other federal
laws;
Make sure that your PHI is protected;
Give you this notice of the Self-Funded Plans' legal duties
and privacy practices with respect to your PHI; and
Follow the terms of the notice that is currently in effect.
pg. v of viii
- Treatment. A Self-Funded Plan may use and disclose your
PHI to doctors, nurses, technicians, and other personnel who
are involved in providing you with medical treatment or
services. For example, a doctor treating you for a broken leg
may need to know if you have diabetes because diabetes
may slow the healing process. The doctor may then tell the
dietitian if you have diabetes so the dietitian can meet any
special menu needs. Different departments may share your
PHI so they can coordinate services you need, such as lab
work, x-rays, and prescriptions.
- Payment. A Self-Funded Plan may use and disclose your
PHI in the course of activities that involve reimbursement
for healthcare, such as determination of eligibility for
coverage, claims processing, billing, obtaining, and
payment of premium, utilization review, medical necessity
determinations, and pre-certifications.
- Healthcare Operations for a Self-Funded Plan. SelfFunded Plans may use and disclose your PHI to carry out
business operations and to assure that all enrollees receive
quality care. For example, a Self-Funded Plan may disclose
your PHI to a business associate who handles claims
processing or administration, data analysis, utilization review,
quality assurance, benefit management, practice
management or referrals to specialists, or provides legal,
actuarial, accounting, consulting, data aggregation,
management, or financial services.
- Healthcare Operations for the UC Healthcare Plan. The
University may also engage a business associate to carry
out healthcare operations on behalf of the entire UC
Healthcare Plan in its role as an organized healthcare
arrangement of a single plan sponsor under HIPAA. The
group health plans participating in the University's organized
healthcare arrangement as of the date of this notice include
UC Care, Blue Shield Health Savings Plan, Optum, Health
Net Blue & Gold, Kaiser Permanente, Western Health
Advantage, Core, High Option Supplement to Medicare,
Last Revised: 10/2015
Blue Shield Medicare PPO, Blue Shield Medicare PPO
without RX, Health Net Seniority Plus, Kaiser Permanente
Senior Advantage, UC Medicare Coordinator Program
Health Reimbursement Account, Post-Deductible Health
Reimbursement Account, Stand Alone Health
Reimbursement Account, Delta Dental, Delta Care USA
Plan, and VSP. You can find a current list of options at
http://ucnet.universityofcalifornia.edu/compensation-andbenefits/.
- Plan Sponsor. A Self-Funded Plan may disclose summary
health information (that is claims data that is stripped of most
individual identifiers) to the University in its role as plan
sponsor in order to obtain bids for health insurance coverage
or to facilitate, modifying, amending, or terminating a plan. A
Self-Funded Plan may also provide the University enrollment
or disenrollment information. In addition, if you request help
from the
University in coordinating your benefits or resolving a
complaint, a Self-Funded Plan may disclose your PHI to
designated University staff, but no PHI may be disclosed to
facilitate employment-related actions or decisions or for
matters involving other benefits or benefit plan. The
University may not further disclose any PHI that is
disclosed to it in these limited instances.
- As Required By Law. A Self-Funded Plan will disclose
your PHI if required to do so by federal, state, or local law,
or regulation.
- To Avert a Serious Threat to Health or Safety. A SelfFunded Plan may disclose your PHI when necessary to
prevent or lessen a serious threat to your health and safety
or the health and safety of the public or another person.
Any disclosure, however, would only be to someone able to
help prevent the threat.
- Military and Veterans. If you are or were a member of the
armed forces, a Self-Funded Plan may release your PHI to
military command authorities as authorized or required by
law. A Self-Funded Plan may also release medical
information about foreign military personnel to the
appropriate military authority as authorized or required by
law.
- Research. In limited circumstances, a Self-Funded Plan
may use and disclose PHI for research purposes, subject to
the confidentiality provisions of state and federal law. Your
PHI may be important to further research efforts and the
development of new knowledge. All research projects
conducted by the University of California must be approved
through a special review process to protect member safety
welfare and confidentiality.
- Workers' Compensation. A Self-Funded Plan may release
PHI for workers' compensation or similar programs as
permitted or required by law. These programs provide
benefits for work-related injuries or illness.
- Health Oversight Activities. A Self-Funded Plan
may disclose PHI to governmental, licensing, auditing,
and accrediting agencies as authorized or required by
Form No: FR.060
pg. vi of vii
law.
- Legal Proceedings. A Self-Funded Plan may disclose PHI
to courts, attorneys, and court employees in the course of
conservatorship and certain other judicial or administrative
proceedings.
- Lawsuits and Disputes. If you are involved in a
lawsuit or other legal proceeding, a Self-Funded Plan
may disclose your PHI in response to a court or
administrative order, or in response to a subpoena,
discovery request, warrant, summons, or other lawful
process.
- Law Enforcement. If authorized or required by law, a
Self-Funded Plan may disclose your PHI under limited
circumstances to a law enforcement official in response to
a warrant or similar process, to identify or locate a
suspect, or to provide information about the victim of a
crime.
- National Security and Intelligence Activities. If
authorized or required by law, a Self-Funded Plan may
release your PHI to authorized federal officials for
intelligence, counterintelligence, and other national security
activities.
- Protective Services for the United States President
and Others. A Self-Funded Plan may disclose your PHI
to authorized federal and state officials so they may
provide protection to the President, other authorized
persons, or foreign heads of state, or conduct special
investigations as authorized or required by law.
- Inmates. If you are an inmate of a correctional institution or
under the custody of a law enforcement official, a SelfFunded Plan may release your PHI to the correctional
institution or law enforcement official, as authorized or
required by law. This release would be necessary for the
institution to provide you with healthcare; to protect your
health and safety or the health and safety of others; or for the
safety and security of the correctional institution.
Required Disclosures
A Self-Funded Plan may be required to disclose your PHI to
the Department of Health and Human Services if the Secretary
is conducting a compliance audit.
Your Rights
You have the following rights regarding the PHI that a SelfFunded Plan maintains about you:
- Right to Inspect and Copy. With certain exceptions you
have the right to inspect and obtain a copy of your PHI that is
maintained by or for a Self-Funded Plan. To inspect and
obtain a copy of the PHI you must submit your request in
writing to the UC Healthcare Plan Privacy Office, 300
Lakeside Drive, 6th Floor, Oakland, CA
94612, Attention: HIPAA Privacy Officer. You may be
charged a fee for the costs of copying mailing or other
supplies associated with your request.
Last Revised: 10/2015
A Self-Funded Plan may deny your request to inspect and/or
obtain a copy in certain limited circumstances. For example,
HIPAA does not permit you to access or obtain copies of
psychotherapy notes. If your request is denied, you will be
informed in writing, and you may request that the denial be
reviewed. The person conducting the review will not be the
person who denied your request. The plan will comply with
the outcome of the review.
- Right to Request an Amendment. If you believe that the
PHI maintained by a Self-Funded Plan is incorrect or
incomplete, you may request that the plan amend the
information. You have the right to request an amendment for
as long as the information is kept by or for the plan. A
request for an amendment should be made in writing and
submitted to the UC Healthcare Plan Privacy Office, 300
Lakeside Drive, 6th Floor, Oakland, CA 94612, Attention:
HIPAA Privacy Officer. In addition, you must provide a
reason that supports your request.
A Self-Funded Plan may deny your request for an
amendment if it is not in writing or does not include a
reason to support the request. In addition, the plan may
deny your request if you ask to amend information that was
not created by the plan; is not part of the PHI maintained
by or for the plan; is not part of the information that you
would be permitted to inspect and copy under the law; or if
the information is accurate and complete. If the request is
granted, the plan will forward your request to other entities
that you identify that you want to receive the corrected
information. For example, if your PHI has been disclosed to
the UC staff so that it may help to coordinate benefits or
resolve a complaint, you may direct the plan to share the
correction with the designated staff members.
- Right to an Accounting of Disclosures. You have the
right to receive an "accounting of disclosures", which is a list
of disclosures such as those that were made of PHI about
you, with the exception of certain documents, including those
relating to treatment, payment, and healthcare operations
and disclosures made to you or consistent with your
authorization. To request an accounting of disclosures, you
must submit your request in writing to the UC Healthcare
Plan Privacy Office, 300 Lakeside Drive, 6th Floor, Oakland,
CA 94612, Attention: HIPAA Privacy Officer.
Your request must state a time period which may not be
longer than six years and may not include dates before
April 14, 2003.
To request a restriction you must submit your request in writing
to the UC Healthcare Plan Privacy Office, 300
Lakeside Drive, 6th Floor, Oakland, CA 94612, Attention:
HIPAA Privacy Officer. Your request should state the
information you want to limit; whether you want to limit the
plan's use disclosure or both; and to whom you want the
limits to apply for example disclosures to your spouse.
- Right to Request Confidential Communications. You
have the right to request that a Self-Funded Plan
communicate with you about medical matters in a certain way
or at a certain location. For example, you can ask that the
plan only contact you at work or by mail to a specific address.
To request confidential communications, you must submit
your request in writing to the UC Healthcare Plan Privacy
Office, 300 Lakeside Drive, 6th Floor, Oakland, CA 94612,
Attention: HIPAA Privacy Officer. The plan will accommodate
all reasonable requests and will not ask you the reason for
your request. Your request must specify how or where you
wish to be contacted.
- Right to a Paper Copy of This Notice. You may ask
the University to give you a copy of this notice at any
time. Even if you have agreed to receive this notice
electronically, you are still entitled to a paper copy of
this notice. To obtain a paper copy of this notice, contact
the UC Healthcare Plan Privacy Office, 300 Lakeside
Drive, 6th Floor, Oakland, CA 94612.
- Other Uses of Medical Information. Other uses and
disclosures of PHI not covered by this notice will be made
only with your written permission. This includes most uses
and disclosures of psychotherapy notes uses and disclosures
of PHI for marketing purposes, and uses and disclosures of
PHI that constitute a sale of PHI. If you provide us permission
to use or disclose your PHI, you may revoke that permission,
in writing, at any time. If you revoke your permission, the plan
will no longer use or disclose your PHI for the reasons stated
in your written authorization. Please understand that the plan
cannot take back any disclosures already made with your
permission.
- Breach. You have the right to be notified of the discovery of
a breach of unsecured PHI.
Your request should indicate in what form you want the list
(for example, on paper or electronically). The first list you
request within a 12-month period will be free. For additional
lists, the plan may charge you for the costs of providing the
list. You will be notified of any costs involved and you may
choose to withdraw or modify your request at that time
before any costs are incurred.
- Right to Request Restrictions. You have the right to
request a restriction or limitation on the use and disclosure
of your PHI for treatment, payment or healthcare
operations, or to request a restriction on the PHI that the
plan may disclose about you to someone who is involved in
Form No: FR.060
your care, or the payment for your care such as a family
member or friend. The plan is not required to agree to your
request. If the plan agrees to your request, it will comply
with the requested restriction unless the information is
needed to provide you emergency treatment or to assist in
disaster relief efforts.
pg. vii of viii
- Genetic Information is Protected Health Information.
In accordance with the Genetic Information
Nondiscrimination Act (GINA), a Self-Funded Plan will not
use or disclose genetic information for underwriting
purposes, which includes eligibility determinations,
premium computations, applications of any pre-existing
condition exclusions, and any other activities related to the
creation, renewal, or replacement of a contract of health
insurance or health benefits.
Last Revised: 10/2015
Changes to This Notice
The Self-Funded Plans reserve the right to change this notice
and to make the revised or changed notice effective for PHI
your plan already maintains on you as well as any
information the plan receives or creates in the future.
A copy of the current notice will be posted at the UC
website at
http://ucnet.universityofcalifornia.edu/forms/pdf/uchealthcare-plan-notice-of-privacy-practices-self-fundedplans.pdf. The notice will contain the effective date on
the first page in the top right-hand corner. In addition, a
copy of the notice that is currently in effect will be given
to new health plan members and thereafter, available
upon request.
Complaints
If you believe your privacy rights have been violated, you may
file a complaint with your Self-Funded Plan, or with the
Secretary of the Department of Health and Human Services.
To file a complaint on your Self-Funded Plan, contact UC
Healthcare Plan Privacy Office, 300 Lakeside Drive, 6th Floor,
Oakland, CA 94612, Attention: HIPAA Privacy Officer. Email
will not be accepted; all complaints must be submitted in
writing.
You will not be retaliated against for filing a complaint.
Questions
If you have questions or for further information regarding this
privacy notice, contact the UC Healthcare Plan
HIPAA Privacy Officer at 1-800-888-8267, press 2 or 510-2873857
Form No: FR.060
pg. viii of viii
Last Revised: 10/2015