your 2013 guide to your benefits january 1 - Seattle University

seattleu.edu

your 2013 guide to your benefits january 1 - Seattle University

www.seattleu.edu

YOUR 2013 GUIDE

TO YOUR BENEFITS

JANUARY 1 – DECEMBER 31, 2013


MAKE THE MOST OF

OPEN ENROLLMENT

• y November 1 – Open Enrollment

Begins

»»

Brown Bag Seminar: 11:30 a.m.

at Law School Courtroom. Learn

about your plan options!

• y November 6 – Annual Benefits Fair:

9 a.m. - 1 p.m. at Student Center

#160 – LeRoux Conference Room

• y November 7 – Brown Bag Seminar:

11:30 a.m. at PIGT Pigott 104-

Auditorium

• y November 9 – Brown Bag Seminar:

11:30 a.m. at Law School Courtroom

• y November 13 - Brown Bag Seminar:

11:30 a.m. at PIGT Pigott 104-

Auditorium

• y November 15 – Brown Bag

Seminar: 11:30 a.m. at PIGT Pigott

104- Auditorium

• y November 27 – Health Screenings:

8:00 a.m. – 2:30 p.m. at Student

Center #160 – LeRoux Conference

Room

• y November 28 – Still have questions?

Come visit Human Resources for oneon-one

help

• y November 30 – Open Enrollment

Ends

• y January 1 – New Plan Year Begins

This benefit guide is intended to provide you

with information on the university’s benefit

offerings. Please read it carefully to fully

understand your options, so you can make

informed decisions.

TABLE OF CONTENTS

2 Eligibility

3 Common Terms

4 Medical and Prescription Drugs

9 Vision

9 Dental

10 Flexible Spending Accounts

11 Life and Disability

12 WorkLife Reources/EAP

12 2013 Benefit Program Costs

14 Contacts

14 Required Notices

ELIGIBILITY

YOU MUST ENROLL FOR BENEFITS COVERAGE

WITHIN YOUR FIRST 30 DAYS OF EMPLOYMENT.

You are eligible to participate in Seattle University benefits if you are a staff

employee who is regularly scheduled to work 20 hours or more per week,

or if you are a faculty member with 17.5 work units on a full academic-year

contract. Your elected coverage under the benefit plans becomes effective

on the first day of the month following or coinciding with your date of hire.

Eligible dependents include:

• y Your legal spouse or a Legally Domiciled Adult (LDA), and

• y Your children (biological, adopted, foster children, stepchildren or

children for whom you have guardianship, children of LDA when

your LDA is also covered), regardless of their marital or student

status up until the end of the month in which they turn 26.

All new faculty and staff must actively enroll into benefits within 30 days

of employment. If you have other coverage available and would like to

waive coverage through the university, you are required to complete the

enrollment form actively waiving coverage and provide proof of other

coverage. If you take no action, you will be defaulted into the Premera PPO

plan with Employee Only coverage.

MAKING CHANGES DURING THE YEAR

Once you enroll for coverage, you may not change or cancel your benefits

until the next open enrollment period held each fall unless you have a life

“qualifying event.” These events include, but are not limited to:

• y Your marriage

• y Birth, adoption or gaining legal custody of a child

• y Divorce or legal separation

• y Loss of coverage under another group insurance plan

• y Loss or gain of your spouse’s or LDA’s eligibility under his or her

employer’s benefit plan

• y The death of your spouse, LDA or a child

If you a experience a life qualifying event, you must notify Human

Resources to change your coverage within 30 days of the event; or 60

days if adding newborns or newly adopted children, or if you, your

spouse/LDA, or eligible dependent child loses coverage under Medicaid or

a State Children’s Health Insurance Program (S-CHIP) or becomes eligible

for state-provided assistance.


ANNUAL OPEN ENROLLMENT

Annual open enrollment is your opportunity to evaluate your benefit options and to make

changes for the upcoming year. Open enrollment is generally held in November each

year. The open enrollment for 2013 benefits is November 1 – 30, 2012.

Your Steps

1. Review your options by reading through open enrollment communications,

check your current elections, and participate in campus brown bags.

2. Consider your needs for the following year. Take a look at claims from the

prior year and anticipate any future needs.

3. Choose a health plan that’s right for you.

4. Determine your FSA contribution. You are required to re-enroll into this benefit

each year.

5. Enroll by completing an enrollment form and returning it to Human Resources

by November 30.

If you don’t make benefit elections during open enrollment, all of your current program

elections – other than Flexible Spending Accounts (FSA) – will automatically carry

forward to the following plan year.

COMMON TERMS

The following definitions will help you better understand your medical plan options:

Premium: A cost that is deducted from your paycheck to provide you access to benefits.

Copayment or Copay: A flat amount paid per visit or prescription.

Deductible: An annual amount paid for services prior to receiving a coinsurance benefit.

Coinsurance: A method of cost-sharing that requires the employee to pay a stated

percentage of all remaining eligible medical expenses after the deductible amount has

been paid.

Out-of-Pocket Maximum: Once an employee has reached this annual amount, any

further eligible costs for the plan year are covered 100% by the plan. This does not

include copays and premiums.

Preventive Care: Preventive care services are routine services that include screenings,

check-ups and patient counseling to prevent illnesses, disease or other health problems.

Preventive care services and recommendations are defined by the U.S. Preventive Task

Force. To find a complete list, visit https://www.premera.com/stellent/groups/public/

documents/xcpproject/ewa_forms_misc.asp.

In-Network Provider: These hospitals and facilities have contracted with your insurance

company to provide services at a negotiated rate. Your out-of-pocket costs will be lower

if you choose to see an in-network provider.

Out-of-Network Provider: These hospitals and facilities are not contracted with Premera

and not part of their network of providers. Your out-of-pocket costs will be higher if you

choose to see an out-of-network provider. Please note, Group Health HMO plan does

not cover out-of-network providers.

Explanation of Benefits (EOB): The EOB is a statement from the insurance company.

The EOB lists what portion of a claim was paid by the plan and what portion of the

payment, if any, you are responsible for.

YOUR 2013 GUIDE TO YOUR BENEFITS ||| 3


MEDICAL AND

PRESCRIPTION DRUGS

The university offers you a choice of medical plans, including a $350

Preferred Provider Organization (PPO) Plan; and New in 2013, a Health

Savings Account (HSA) Plan through Premera Blue Cross. A third plan

option is an HMO underwritten by Group Health Cooperative. Although

the plans generally cover the same medical services, they are different in

three important ways: what providers and facilities you have access to, how

much money you spend when you receive services and how much you pay

in payroll deductions. Which plan is best for you will depend on your and

your family’s health care needs.

HMO PLAN

Underwritten by Group Health Cooperative

The Group Health HMO Plan is a Health Maintenance Organization

(HMO) plan. This plan has no deductible and requires a copayment for

certain services. To receive care, you must use a Group Health provider or

facility for services to be covered. You do not have to be referred by your

primary care physician to see many specialists in network.

PPO PLAN

Administered by Premera Blue Cross

The PPO Plan has a deductible of $350 per individual and a maximum

of $700 for a family. Once you have met your deductible, you then pay

a percentage of the expenses, called coinsurance. If your coinsurance

and deductible reach an amount called the out-of–pocket maximum, the

plan will pay 100% of your eligible expenses for the rest of the plan year,

excluding copays and premiums. With the PPO Plan you pay a higher

premium in exchange for the lower deductible and out-of-pocket maximum.

If you receive care from an in-network provider, you will receive the highest

level of benefit coverage available.


YOUR 2013 GUIDE TO YOUR BENEFITS ||| 5

HEALTH SAVINGS ACCOUNT (HSA) PLAN

Administered by Premera Blue Cross NEW FOR 2013

Before the plan pays benefits for a covered person each plan year, individuals must pay the first $2,000 of eligible health expenses for

non-preventive services. This amount is called the plan year deductible. The deductible for coverage of the employee plus one or more

dependents is $4,000. Once you have met your deductible, you will pay a percentage of the expenses for coinsurance. If your coinsurance

and deductible reach the out-of–pocket maximum, the plan will pay 100% of your eligible expenses for the rest of the plan year,

excluding premiums. To help you pay out-of-pocket costs, the university will contribute to a tax-advantaged Health Savings Account (HSA),

administered through Fidelity.

How the HSA Works

An HSA is a tax-advantaged medical savings account available to individuals that enroll in a qualified high deductible plan such as the

University’s HSA Plan. Once enrolled, an account is opened in your name with Fidelity. Seattle University will make monthly contributions

to your account. You can choose to add your own paycheck deferrals to the same account. You may use these HSA dollars (including

earnings) to pay for eligible medical expenses or you can save them as a long-term strategy to pay for medical expenses in retirement (for

example).

Seattle University’s 2013 monthly contribution to your HSA is based on the level of coverage you choose:

• y Employee Only: $50 per month

• y Employee Plus One or More Dependents: $100 per month

Special Incentive: Faculty and staff members that elect the HSA Plan on January 1, 2013 will receive an additional $200 ($400

for dependents) contribution to their HSA in the month of January. The university’s total contribution to the HSA in 2013 will be

$750 for Employee Only and $1,500 for those enrolling with one or more dependents.

Who’s Eligible?

You’re eligible if you meet the following criteria:

• y You select the HSA plan as your medical coverage.

• y You’re not enrolled in Medicare.

• y You can’t be claimed as a dependent on someone else’s tax return.

• y You are not enrolled in other medical coverage (i.e., dual covered under your spouse’s plan) unless it is considered a qualified high

deductible health plan with a deductible.

Please note that you aren’t eligible to participate in an HSA if your spouse is enrolled in a Health Care Flexible Spending Account.

Your HSA Contribution Maximum

In addition to the monthly contributions the university makes on your behalf, you may also make paycheck contributions to your account, up

to the IRS limit. The following contribution limits apply if you enroll on January 1, 2013:

Medical Coverage Total Maximum Contribution University Contribution Maximum Employee

Contribution*

Employee Only $3,250 $750 $2,500

Employee Plus One or

More Dependents

If you are 55 or older, you may add a “catch-up” contribution of $1,000.

$6,450 $1,500 $4,950


Eligible Expenses

You can use your HSA for qualified health care expenses related to yourself

or any tax dependent. A list of these expenses is available on the IRS website

at www.irs.gov. In general, most expenses related to medical, dental and

vision care count as a qualified expense.

Expenses for your LDA and his/her child(ren) are not eligible for

the HSA unless your LDA is considered a dependent for income tax

purposes.

Why Enroll in an HSA

An HSA helps you set aside tax-advantaged dollars to meet future health

care needs.

• You decide when to use the money in your savings account. You

even keep the account when you leave the University.

• The university contributes dollars to the HSA.

• Your payroll premium contribution is lower.

• It rolls over. Unlike a Health Care FSA, any unused dollars rollover

each year and will be available when you need them to pay for

eligible health expenses.

• It can help you prepare for retirement. An HSA can help you set

aside dollars now to pay for future medical expenses. A 2009

Fidelity survey estimated that the average married couple will pay

$225,000 for medical care between the ages of 65 and 80.

HSA TRIPLE TAX BENEFITS:

• You will not pay federal income or social security tax, and in most

cases state income tax, on HSA contributions.

• Your HSA balance earns tax-free investment returns.

• You can withdraw tax-free money to pay for qualified health care

expenses before or after retirement.

As medical costs continue to rise, it’s important to make health care

saving a part of your long-term plans. If you’d like to take a more

detailed look at how an HSA works, watch this 15-minute video.


YOUR 2013 GUIDE TO YOUR BENEFITS ||| 7

Annual Deductible

PREMERA BLUE CROSS

GROUP HEALTH

PPO Plan HSA Plan HMO

In-Network Out-of-Network In-Network Out-of-Network In-Network

Individual $350 $2,000 $4,000 None

Family $700 $4,000 $8,000 None

Out-of-Pocket Maximums (includes deductible)

Individual $2,850 $4,000 N/A $2,000

Family $5,700 $8,000 N/A $4,000

Preventive Care

Well-Baby Exams 100% 60% after

deductible

Adult Physical Exam 100% 60% after

deductible

Well-Women Exams/Screenings 100% 60% after

deductible

Immunizations 100% 60% after

deductible

Professional Services

Doctor Office Visit $20 then 100% 60% after

deductible

Urgent Care $20 then 100% 60% after

deductible

Diagnostic Lab/X-ray

Inpatient Hospital Services

Outpatient Hospital Services

Emergency Room

(copay waived if admitted)

90% after

deductible

90% after

deductible

90% after

deductible

60% after

deductible

60% after

deductible

60% after

deductible

$100 copay, then deductible/

coinsurance

100% 50% after

deductible

100% 50% after

deductible

100% 50% after

deductible

100% 50% after

deductible

90% after

deductible

90% after

deductible

90% after

deductible

90% after

deductible

90% after

deductible

90% after

deductible

50% after

deductible

50% after

deductible

50% after

deductible

50% after

deductible

50% after

deductible

50% after

deductible

100%

100%

100%

100%

$20 then 100%

$20 then 100%

100%

100%

$20 then 100%

$100 copay for

GHC or non-GHC

facility

Ambulance 80% after deductible 100%

Prescription Drugs (retail)

30-day supply

Generic $10 90% after deductible $10

Preferred Brand $25 $25

Non-Preferred Brand $50 N/A

Prescription Drugs (mail-order)

90-day supply

Generic $20 90% after deductible $ $20 0

Preferred Brand $50 $50

Non-Preferred Brand $100 N/A

This summary is provided for general information only, please refer to the Summary of Benefits and Coverage available at:

www.seattleu.edu/hr/Required_Benefit_Notices.aspx.


Plan Shopping Help

Premera’s Plan Comparison Tool is available to help you decide which

health plan is best for you and your family. This online tool helps you

estimate annual health care costs based on national averages. You can

adjust usage to fit your own situation and the estimated cost of each plan

updates in real time.

• Estimate your health care usage.

Allows you to adjust your expected usage with the sliding bars.

• Change coverage levels.

Shows how adding or removing a spouse and/or dependents

changes the costs for each plan. See a side-by-side comparison

of key plan information such as deductibles, copays, and

coinsurance values.

• Print a hard copy of your comparison for your records.

Includes details and costs for the selected plan.

• See the tax benefit of contributing to an HSA.

Shows you the estimated tax benefit.

You enter the number of doctor visits, prescription drugs and other common

health usage for your family. The tool estimates your out-of-pocket costs.

For example, if your family expects to visit the doctor about four times a

year, you will be able to show this on your Personalized Usage sliding bar.

After you change the information to match what you think will be needed

for you and your family, your report is done. It shows what your costs might

be, including deductibles, copays and out-of-pocket costs.

Access the Premera Plan Shopping application here: https://www.premera.

com/stellent/groups/public/documents/xcpproject/seattle-universityemployee.aspx


YOUR 2013 GUIDE TO YOUR BENEFITS ||| 9

VISION

Underwritten by Vision Service Plan (VSP)

If you elect coverage in a Seattle University medical plan, you are automatically covered for VSP vision coverage. The vision plan includes

an eye exam every 12 months, lenses or contacts once ever 12 months and frames once every 24 months. In addition, VSP provides you

additional savings opportunities, including discounts on additional glasses and sunglasses, lens options and discounts on laser vision

correction. You will receive the highest level of benefit by using an in-network provider.

VISION PLAN

Benefit In Network Out-of-Network

Exam $20 copay Reimbursed up to $50, after $20 copay

Lenses

$20 copay, then 100% for single vision, bifocal,

trifocal, and lenticular lenses

$20 copay then: Single vision up to $50

Bifocal up to $75

Trifocal up to $100

Lenticular up to $125

Frames $130 allowance Reimbursed up to $70, after $20 copay

Contact Lenses

Elective $130 allowance Reimbursed up to $105, after $20 copay

Medically Necessary $20 copay Reimbursed up to $210, after $20 copay

If you enroll in the Group Health Cooperative HMO medical plan, your HMO coverage includes on annual eye exam every 12 months

(subject to office visit copay).

DENTAL

Underwritten by Washington Dental Service (WDS)

Your dental plan is a preferred provider organization (PPO) plan, underwritten by Washington Dental Service. Under this plan you are free

to go to any licensed dentist you choose — but if you go to a dentist who is a member of Washington Dental Service’s network, you will

reduce your out-of-pocket costs. The highlights of your dental plan are presented below.

PPO DENTAL PLAN

Benefit Preferred Provider Non-Preferred Provider

Annual Maximum Benefit

Calendar Year Deductible

$1,500 individual

$50 individual/$150 family

Preventive Services Plan pays 100%; deductible waived Plan pays 80%; deductible waived

Basic Services Plan pays 80% Plan pays 70%

Major Services Plan pays 50% Plan pays 40%

Orthodontia

(children only)

Plan pays 50%, up to a maximum lifetime benefit of $1,500

FLEXIBLE SPENDING ACCOUNTS

Administered by Flex-Plan Services

Flexible Spending Accounts (FSAs) allow you to set aside pre-tax dollars to pay for eligible expenses each year. This means your

contributions will be deducted from your paycheck before your pay is taxed. You will not pay federal income or social security tax, and

in most cases state income tax, on flexible spending account contributions.


The university offers you two FSAs:

HEALTH CARE SPENDING ACCOUNT

Allows you to pay eligible health care expenses for yourself and your

eligible dependents with tax-free dollars. Eligible expenses may include

deductibles, copays, out-of-pocket vision or dental expenses, and prescribed

over-the-counter medications. The eligible amount to contribute to a Health

Care FSA effective January 1, 2013 per the IRS is $2,500.

Reimbursable claims may be incurred during January 1 through

December 31 each year. You may submit claims for yourself and your

eligible dependents until March 31, 2014 for claims incurred in 2013.

NEW! DON’T WAIT FOR REIMBURSEMENT

Rather than completing a claim form and waiting for reimbursement for your

out of pocket eligible expenses, you can elect a Benny Debit Card and pay

your provider directly for qualified medical care expenses.

DEPENDENT CARE SPENDING ACCOUNT

Enables you to pay for work-related dependent care expenses with tax-free

dollars. Eligible expenses may include daycare centers, in-home child care

and before/after school care. You can set aside $5000 ($2500 if married

and filing separately).

Who’s Eligible?

You’re eligible to enroll in a Health Care FSA as long as you or your spouse

aren’t actively contributing to a Health Savings Account (HSA). If you’re

enrolled in a HSA, you can still take advantage of the tax benefits of a

Dependent Care Spending Account.

How an FSA Works

If you elect to participate in an FSA, you must do the following:

• y Each year, during Open Enrollment, you will need to enroll and

determine the amount you want to contribute per paycheck.

• y You may contribute up to $2,500 per plan year to the Health

Care FSA.

• y You can also contribute up to $5,000 per plan year to the Dependent

Care FSA ($2,500 if married and filing separately).

• y You must actively enroll for this benefit each year, as your

participation will not automatically roll over.

• y Contributions to your FSA are deducted from your paycheck in equal

amounts throughout the year before taxes are taken out, which means

more money in your wallet.

To learn more about reimbursable expenses, visit the Flex-Plan website:

www.flex-plan.com > Click on ‘Participant.’

Reminder: Over the counter medications are no longer eligible for

reimbursement through an FSA or HSA, unless prescribed by a doctor.


YOUR 2013 GUIDE TO YOUR BENEFITS ||| 11

LIFE AND DISABILITY

Underwritten by Cigna (New for 2013)

All benefit eligible faculty and staff are automatically covered by the basic life and basic accidental death and dismemberment (AD&D)

insurance plans. The university pays the full cost of these plans, which are insured through Cigna. You may also purchase additional

coverage for yourself and coverage for your dependents.

Basic Life/AD&D Insurance

The university provides you coverage equivalent of your annual rate of pay to a maximum of $50,000 (for a total of $100,000 basic life

and AD&D coverage). Life insurance protects your family from financial hardship in the event of your death. AD&D pays a benefit when

death is due to an accident or when you experience a certain loss of functionality.

BE PROTECTED.

Here are some good reasons to think about Optional Life Insurance:

• y 34% of American households would have immediate trouble meeting everyday living expenses if their primary wage earner died.

• y In 2009, the average funeral cost was around $7,500. Once all funeral related costs are factored in, the typical funeral service will

cost the average family between $8,000 and $10,000.

• y Unintentional injuries are the fifth leading cause of death overall.

For more information on how much life insurance you need, visit Cigna’s online calculator at www.cigna.com\lifecalculator.

Optional Life Insurance

Additional Coverage for You. You may purchase additional life insurance from one to four times your annual pay to a maximum of

$500,000. You pay the cost of this coverage through after-tax payroll deductions. If you choose more than $200,000 of coverage

(including the basic benefit), you will be required to provide evidence of good health before Cigna’s coverage will become effective. You

will also have to provide evidence of good health if you do not enroll in the optional life insurance plan within 30 days of the date you

become eligible for coverage, or if you later decide to increase your coverage amount. If you were covered for more than $200,000 (or

$20,000 for your spouse) by Prudential in 2012, Cigna will accept this same coverage level without further evidence of your insurability.

Coverage for Your Family. In addition to buying extra life insurance coverage for yourself, you may purchase life insurance for your spouse

(or LDA) and children. You may only purchase coverage for your family members if you purchase coverage for yourself under the optional

life insurance plan. You will pay the full cost of your family members’ coverage through after-tax payroll deductions.

• y Spouse (or LDA): You may purchase optional life insurance to a maximum benefit of $100,000. Evidence of good health will be

required for amounts in excess of $20,000.

• y Child(ren): You may purchase child life insurance in $5,000 increments to a maximum benefit of $10,000.

Rates are determined based on your age and the amount of insurance requested.

Optional AD&D

Additional AD&D insurance, beyond the basic amount provided by the university, is also available at your expense. You may elect between

$100,000 and $500,000 of optional coverage for either yourself or you and your family. You do not need to provide evidence of

insurability if you are electing or increasing optional AD&D during open enrollment.

BENEFICIARY DESIGNATION

It is important to review your beneficiary designation each year to ensure it’s current. Updates can be made at any time by completing the

Cigna Beneficiary Designation Form, available at: http://www.seattleu.edu/hr/OE_Forms.aspx.


Long-term Disability

The long-term disability plan provides you monthly income protection after

180 days of being unable to work due to a disabling condition. The university

pays the cost of this coverage, and enrollment is automatic on the first of the

month following or coinciding with your first anniversary as a benefits-eligible

employee. The plan pays 60% of your monthly earnings up to a maximum

benefit of $9,000 and may continue until your social security retirement age.

WorkLife Resources and EAP

New for 2013! The university pays 100% of the cost of services provided

by Wellspring Family Services. Wellspring is your community resource and

referral service for help with daily life challenges including child and elder

care, parenting and legal/financial counseling. Employees and their

family members may call Wellspring at 1.800.533.7798 or visit online

at www.wfseap.org.

Through Wellspring’s Employee Assistance Program, trained counselors

provide confidential assistance with life’s most pressing challenges including:

• y depression, stress or grief

• y marital and parenting problems

• y alcohol and substance abuse

• y conflicts

Employees and family members are eligible for up to three face-to-face

assessment and counseling sessions per issue, per year. Wellspring’s EAP is

staffed with licensed clinicians and skilled behavioral health care professionals

who will assess your needs and refer you to a local provider if appropriate.

2013 BENEFIT PROGRAM COSTS

Seattle University pays most of the cost of medical plan premiums for benefits

eligible faculty and staff and their families. Also, the University pays 100% of

the premium for vision, basic life, basic accidental death and dismemberment

(AD&D) and long-term disability. Your premium cost for medical coverage is

based on your annual pay rate and coverage level. Premiums for you, your

spouse and dependent children are deducted on a pre-tax basis (except for

optional life/AD&D). Pre-tax means the deductions are taken from your gross

pay before federal withholding and Social Security taxes are calculated and

withheld. If you choose to contribute to a flexible spending account or health

savings account, these deductions are also on a pre-tax basis.

Due to IRS regulations, health premiums for your Legally Domiciled Adult

(LDA) and for the dependent children of your LDA are deducted on an aftertax

basis. Additionally you will be charged imputed income for the coverage

of your LDA and your LDA’s dependents.


YOUR 2013 GUIDE TO YOUR BENEFITS ||| 13

Premiums shown are monthly and are based on your annual rate of pay as of November 1, 2012, or your employment date if hired

after November 1. Your payroll contribution amount will not change during the 2013 plan year, if you have a 2013 salary adjustment.

MEDICAL

Annual Rate of Pay Premera PPO Plan Premera HSA Plan Group Health HMO

Employee Only

$36,000 or less $26 $10 $20

$36,001 - $52,000 $51 $23 $40

$52,001 - $77,000 $64 $36 $50

$77,001 - $117,000 $77 $49 $60

$117,001 - $170,000 $89 $61 $70

$170,001 + $102 $74 $80

Employee & Spouse or LDA

$36,000 or less $158 $85 $121

$36,001 - $52,000 $315 $242 $242

$52,001 - $77,000 $347 $274 $266

$77,001 - $117,000 $394 $321 $303

$117,001 - $170,000 $425 $352 $327

$170,001 + $473 $400 $363

Employee & Child(ren)

$36,000 or less $105 $80 $81

$36,001 - $52,000 $210 $185 $162

$52,001 - $77,000 $231 $206 $178

$77,001 - $117,000 $263 $238 $203

$117,001 - $170,000 $284 $259 $219

$170,001 + $315 $290 $243

Employee & Spouse or LDA/Child(ren)

$36,000 or less $218 $105 $163

$36,001 - $52,000 $435 $302 $325

$52,001 - $77,000 $479 $346 $358

$77,001 - $117,000 $544 $411 $406

$117,001 - $170,000 $587 $454 $439

$170,001 + $653 $520 $488

Washington Dental Service

Employee Only $0

Employee & 1 Dependent $45

Employee & 2+ Dependents $67

DENTAL


CONTACTS

Benefit Contact Group Number Website Phone Number

Medical

Health Savings Account

(HSA)

Dental

Vision

Life/AD&D/LTD

Flexible Spending

Accounts

WorkLife Resources/

Employee Assistance

Program

Premera Blue

Cross

Group Health

Cooperative

4000040 www.premera.com

69200 www.ghc.org

Customer Service:

1-800-722-1471

24-Hour NurseLine:

1-800-841-8343

Customer Service:

1-888-901-4636

24-Hour NurseLine:

1-800-297-6877

Fidelity N/A www.netbenefits.fidelity.com 1-800-343-0860

Washington

Dental Service

Vision Service

Plan (VSP)

Cigna

Flex-Plan

Services

387 www.deltadentalwa.com 1-800-554-1907

623-5178 www.vsp.com 1-800-877-7195

Basic/Supplemental Life:

FLX 964865

Basic/Supplemental AD&D:

OK 966475

Long-Term Disability:

LK 963399

www.cigna.com 1-800-362-4462

N/A www.flex-plan.com 1-800-669-3539

Wellspring N/A www.wfseap.org 1-800-533-7798

Retirement Fidelity 87239 www.netbenefits.fidelity.com 1-800-343-0860

Wellness

Seattle

University, HR

Live SU/

Limeade

N/A

https://liveseattleu.limeade.

com/User/home.aspx

Ruth Sanoy N/A N/A 206-296-5894

YOUR RIGHTS

MEDICAL BENEFITS

Mastectomy Benefits

The Women’s Health and Cancer Right Act of 1998 requires medical plans

that offer mastectomy benefits to also provide coverage for reconstructive

surgery benefits.

Coverage extends to:

• y Reconstructive surgery of the breast on which the mastectomy is

performed;

• y Treatment to produce a symmetrical appearance following a

mastectomy; prostheses; and physical complications for all stages

of a mastectomy, including lymphedemas (swelling associated with the

removal of lymph nodes).

As with the other covered services provided under your medical plan,

annual deductibles, copays and coinsurance may apply to these

mastectomy benefits.

Organ Transplant

This plan doesn’t provide benefits for an organ, bone marrow or stem

cell transplant, including any procedure associated with the transplant (for

example, testing, blood typing, chemotherapy, radiation or hospitalization)

for the first 6 consecutive months after your effective date.

Newborns’ Act

Group health plans and health insurance issuers generally may not, under

federal law, restrict benefits for any hospital length of stay in connection

with childbirth for the mother or newborn child to less than 48 hours

following a vaginal delivery, or less than 96 hours following a cesarean

section. However, federal law generally does not prohibit the mother’s

or newborn’s attending provider, after consulting with the mother, from

discharging the mother or her newborn earlier than 48 hours (or 96 hours

as applicable). In any case, plans and issuers may not, under federal

law, require that a provider obtain authorization from the plan or the

insurance issuer for prescribing a length of stay not in excess of 48 hours

(or 96 hours).


Out-of-Area Benefits

If you are traveling or living outside of Washington and need medical care, you may use a Blue

Cross or BlueShield PPO provider to receive the same benefits as the preferred level of your plan.

When you are outside of the service area and need medical care, call the BlueCard Access Line

at (800) 810-BLUE (2583) for information on the nearest PPO doctors and hospitals. The doctor or

hospital will verify your membership and coverage information after you present your identification/

membership card. The doctor or hospital will electronically route your claim to your Blue Cross plan

for processing. Because all PPO providers are paid by the plan directly, you are not required to pay

for the care at time of service and then wait for reimbursement. You will only need to pay for out-ofpocket

expenses, such as non-covered services, deductible, copays and coinsurance.

Special Enrollment Rights

If you are declining 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 toward the other coverage).

You may also be able to enroll yourself or your dependents in the future if you or your dependents

lose health coverage under Medicaid or your state Children’s Health Insurance Program, or

become eligible for state premium assistance for purchasing coverage under a group health plan,

provided that you request enrollment within 60 days after that coverage ends or after you become

eligible for premium assistance.

In addition, 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 60 days after the marriage, birth, adoption, or placement for adoption. To request

special enrollment or obtain more information, contact your Human Resources Department. Refer to

your benefit book for details.

Certificate of Creditable Coverage

HIPAA Certificates of Creditable Coverage certify prior periods of medical coverage and may

reduce or eliminate the pre-existing or conditions limitation period for new entrants to the plan. It

is your responsibility to submit these certificates to Human Resources when enrolling yourself or

family members into the medical plan. Note: Creditable coverage includes group health (including

COBRA), comprehensive individual health, Medicare, Medicaid, CHAMPUS, Peace Corp. Act Plan,

state risk pool Plans and the Federal Employee Health Benefit Plan.

Statement of ERISA Rights

As a participant in the Plan you are entitled to certain rights and protections under the Employee

Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all participants shall be

entitled to:

• y Examine, without charge, at the Plan Administrator’s office and at other specified locations, the

documents governing the plan, including the insurance contract and a copy of the latest annual

report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at

the Public Disclosure Room of the Employee Benefits Security Administration.

• y Obtain, upon written request to the Plan Administrator, copies of documents governing the

operation of the plan, including insurance contracts, and copies of the latest annual report (Form

5500 Series) and updated summary plan description. The Plan Administrator may make a

reasonable charge for the copies.

• y Receive a summary of the Plan’s annual financial report, if any. The Plan Administrator is required

by law to furnish each participant with a copy of this summary annual report, if any.

You have a right to continue health care coverage for yourself, spouse or dependents if there is a

loss of coverage under the plan as a result of a qualifying event. You or your dependents may have

to pay for such coverage. Review this summary plan description and the documents governing the

Plan on the rules governing your COBRA continuation coverage rights.

You have rights regarding reduction or elimination of exclusionary periods of coverage for

preexisting conditions under your group health plan, if you have creditable coverage from another

plan. You should be provided a certificate of creditable coverage, free of charge, from your group

health plan or health insurance issuer when you lose coverage under the Plan, when you become

YOUR 2013 GUIDE TO YOUR BENEFITS ||| 15


entitled to elect COBRA continuation coverage, when your COBRA continuation

coverage ceases, if you request it before losing coverage, or if you request it up to 24

months after losing coverage. Without evidence of creditable coverage, you may be

subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees)

after your enrollment date in your coverage.

In addition to creating rights for participants, ERISA imposes duties upon the people

who are responsible for operation of the Plan. These people, called “fiduciaries” of

the Plan, have a duty to operate the Plan prudently and in the interest of you and other

Plan participants and beneficiaries. Fiduciaries who violate ERISA may be removed and

required to make good any losses they have caused the Plan.

No one, including the Company or any other person, may fire you or discriminate

against you in any way to prevent you from obtaining welfare benefits or exercising

your rights under ERISA.

If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a

right to know why this was done, to obtain copies of documents relating to the decision

without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce these rights. For instance, if you

request a copy of plan documents or the latest annual report from the Plan Administrator

and do not receive them within 30 days, you may file suit in a Federal court. In such

a case, the court may require the Plan Administrator to provide the materials and pay

you up to $110 a day until you receive the materials, unless the materials were not sent

because of reasons beyond the control of the Plan Administrator. If you have a claim

for benefits which is denied or ignored, in whole or in part, you may file suit in a state

or Federal court. In addition, if you disagree with the plan’s decision or lack thereof

concerning the qualified status of a domestic relations order or a medical child support

order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse

the Plan’s money, or if you are discriminated against for asserting your rights, you may

seek assistance from the U.S. Department of Labor, or you may file suit in a Federal

court. The court will decide who should pay court costs and legal fees. If you are

successful, the court may order the person you have sued to pay these costs and fees.

If you lose, the court may order you to pay these costs and fees, for example, if it finds

your claim is frivolous.

If you have any questions about your Plan, you should contact the Plan Administrator.

If you have any questions about this statement, or your rights under ERISA, or if you

need assistance or information regarding your rights under HIPAA, you should contact

the nearest office of the Employee Benefits Security Administration, U.S. Department

of Labor, listed in your telephone directory or the Division of Technical Assistance

and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor,

200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain

certain publications about your rights and responsibilities under ERISA by calling the

publications hotline of the Employee Benefits Security Administration.

MEDICARE PART D

Medicare Part D Prescription Drug Notice

Please read this notice carefully and keep it where you can find it. This notice has

information about your current prescription drug coverage with Seattle University and

about your options under Medicare’s prescription drug coverage. This information can

help you decide whether or not you want to join a Medicare drug plan. Information about

where you can get help to make decisions about your prescription drug coverage is at the

end of this notice.

Medicare prescription drug coverage became available in 2006 to everyone with

Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or

join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug

coverage. All Medicare drug plans provide at least a standard level of coverage set by

Medicare. Some plans may also offer more coverage for a higher monthly premium.


YOUR 2013 GUIDE TO YOUR BENEFITS ||| 17

Seattle University has determined that the prescription drug coverage

offered by the health plan is, on average for all plan participants, expected

to pay out as much as standard Medicare prescription drug coverage pays

and is considered Creditable Coverage.

Because your existing coverage is, on average, at least as good as

standard Medicare prescription drug coverage, you can keep this coverage

and not pay a higher premium (a penalty) if you later decide to join a

Medicare drug plan.

You can join a Medicare drug plan when you first become eligible for

Medicare and each year from October 15th through December 7th. This

may mean that you may have to wait to join a Medicare drug plan and that

you may pay a higher premium (a penalty) if you join later.

You may pay that higher premium (a penalty) as long as you have

Medicare prescription drug coverage. However, if you lose creditable

prescription drug coverage, through no fault of your own, you will be

eligible for a 60-day Special Enrollment Period (SEP) because you lost

creditable coverage to join a Part D plan. In addition, if you lose or decide

to leave employer/union sponsored coverage; you will be eligible to join

a Part D plan at that time using an Employer Group Special Enrollment

Period. You should compare your current coverage, including which drugs

are covered at what cost, with the coverage and costs of the plans offering

Medicare prescription drug coverage in your area.

If you do decide to join a Medicare drug plan, your Seattle University

coverage will be affected. Benefits will not be coordinated with a Medicare

Part D plan.

If you do decide to join a Medicare drug plan and drop your Seattle

University prescription drug coverage, be aware that you and your

dependents may not be able to get this coverage back. You should also

know that if you drop or lose your coverage with Seattle University and

don’t join a Medicare drug plan within 63 continuous days after your

current coverage ends, you may pay a higher premium (a penalty) to join a

Medicare drug plan later.

If you go 63 continuous days or longer without prescription drug coverage

that’s at least as good as Medicare’s prescription drug coverage, your

monthly premium may go up by at least 1% of the base beneficiary

premium per month for every month that you did not have that coverage.

For example, if you go nineteen months without coverage, your premium

may consistently be at least 19% higher than the base beneficiary premium.

You may have to pay this higher premium (a penalty) as long as you have

Medicare prescription drug coverage. In addition, you may have to wait

until the following November to join.

Contact the Seattle University Benefits Team at 206.296.5894 for further

information. Note: You’ll get this notice each year. You will also get

it before the next period you can join a Medicare drug plan, or if this

coverage through Seattle University changes. You also may request a copy.

More detailed information about Medicare plans that offer prescription

drug coverage is in the “Medicare & You” handbook. If Medicare eligible,

you’ll get a copy of the handbook in the mail every year from Medicare.

You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug

coverage:

• y Visit www.medicare.gov.

• y Call your State Health Insurance Assistance Program (see the inside

back cover of your copy of the “Medicare & You” handbook for their

telephone number) for personalized help.

• yCall 1-800-MEDICARE (1-800-633-4227). TTY users should

call 1-877-486-2048.

• y If you have limited income and resources, extra help paying for

Medicare prescription drug coverage is available. For information

about this extra help, visit Social Security on the Web at

www.socialsecurity.gov, or call them at 1-800-772-1213

(TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join

one of the Medicare drug plans, you may be required to provide a copy

of this notice when you join to show whether or not you have maintained

creditable coverage and whether or not you are required to pay a higher

premium (a penalty).

MEDICAID AND THE CHILDREN’S

HEALTH INSURANCE PROGRAM (CHIP)

Medicaid and CHIP Offer Free or Low-Cost

Health Coverage to Children and Families

If you are eligible for health coverage from your employer, but are unable

to afford the premiums, some States have premium assistance programs that

can help pay for coverage. These States use funds from their Medicaid or

CHIP programs to help people who are eligible for employer-sponsored

health coverage, but need assistance in paying their health premiums.

If you or your dependents are already enrolled in Medicaid or CHIP and

you live in a State listed below, you can contact your State Medicaid or

CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP,

and you think you or any of your dependents might be eligible for either

of these programs, you can contact your State Medicaid or CHIP office or

dial 1-877-KIDS-NOW or www.insurekidsnow.gov to find out how

to apply. If you qualify, you can ask the State if it has a program that might

help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium

assistance under Medicaid or CHIP, your employer’s health plan is

required to permit you and your dependents to enroll in the plan – as long

as you and your dependents are eligible, but not already enrolled in the

employer’s plan. This is called a “special enrollment” opportunity, and you

must request coverage within 60 days of being determined eligible for

premium assistance.

If you live in one of the following States, you may be eligible for assistance

paying your employer health plan premiums. You should contact your State

for further information on eligibility.


To see if any more States have added

a premium assistance program since

April 16, 2010, or for more information

on special enrollment rights, you can

contact either:

ALABAMA – MEDICAID

www.medicaid.alabama.gov

1-800-362-1504

ALASKA – MEDICAID

http://health.hss.state.ak.us/dpa/

programs/medicaid/

(Outside of Anchorage): 1-888-318-8890

(Anchorage): 907-269-6529

ARIZONA – CHIP

www.azahcccs.gov/applicants/default.

aspx

1-877-764-5437

ARKANSAS – CHIP

www.arkidsfirst.com/

1-888-474-8275

CALIFORNIA – MEDICAID

www.dhcs.ca.gov/services/Pages/

TPLRD_CAU_cont.aspx

1-866-298-8443

COLORADO –

MEDICAID AND CHIP

Medicaid: www.colorado.gov/

Medicaid: 1-800-866-3513

CHIP: www.CHPplus.org

CHIP Phone: 303-866-3243

FLORIDA – MEDICAID

www.fdhc.state.fl.us/Medicaid/

index.shtml

1-866-762-2237

GEORGIA – MEDICAID

http://dch.georgia.gov/

(Click on Programs, then Medicaid)

1-800-869-1150

IDAHO – MEDICAID AND CHIP

Medicaid: www.accesstohealthinsurance.

idaho.gov

Medicaid: 1-800-926-2588

CHIP: www.medicaid.idaho.gov

CHIP: 1-800-926-2588

INDIANA – MEDICAID

www.in.gov/fssa/2408.htm

1-877-438-4479

IOWA – MEDICAID

www.dhs.state.ia.us/hipp/

1-888-346-9562

KANSAS – MEDICAID

www.khpa.ks.gov

800-766-9012

KENTUCKY – MEDICAID

http://chfs.ky.gov/dms/default.htm

1-800-635-2570

LOUISIANA – MEDICAID

www.la.hipp.dhh.louisiana.gov

1-888-342-6207

MAINE – MEDICAID

www.maine.gov/dhhs/oms/

1-800-321-5557

MASSACHUSETTS –

MEDICAID AND CHIP

Medicaid & CHIP: www.mass.gov/

MassHealth

Medicaid & CHIP: 1-800-462-1120

MINNESOTA – MEDICAID

www.dhs.state.mn.us/

(Click on Health Care, then

Medical Assistance)

1-800-657-3739

MISSOURI – MEDICAID

www.dss.mo.gov/mhd/index.htm

573-751-6944

MONTANA – MEDICAID

http://medicaidprovider.hhs.mt.gov/

clientpages/clientindex.shtml

1-800-694-3084

NEBRASKA – MEDICAID

www.dhhs.ne.gov/med/medindex.htm

1-877-255-3092

NEVADA – MEDICAID AND CHIP

Medicaid: http://dwss.nv.gov/

Medicaid: 1-800-992-0900

CHIP: http://www.nevadacheckup.nv.org/

CHIP: 1-877-543-7669

NEW HAMPSHIRE – MEDICAID

www.dhhs.state.nh.us/DHHS/

MEDICAIDPROGRAM/default.htm

1-800-852-3345 x 5254

NEW JERSEY – MEDICAID

AND CHIP

Medicaid: http://www.state.nj.us/

humanservices/dmahs/

clients/medicaid/

Medicaid: 1-800-356-1561

CHIP: http://www.njfamilycare.org/

index.html

CHIP: 1-800-701-0710

NEW MEXICO –

MEDICAID AND CHIP

Medicaid: www.hsd.state.nm.us/mad/

index.html

Medicaid: 1-888-997-2583

CHIP: www.hsd.state.nm.us/mad

/index.html

(Click on Insure New Mexico)

CHIP: 1-888-997-2583


YOUR 2013 GUIDE TO YOUR BENEFITS ||| 19

NEW YORK – MEDICAID

http://www.nyhealth.gov/health_care/medicaid/

1-800-541-2831

NORTH CAROLINA – MEDICAID

http://www.nc.gov

919-855-4100

NORTH DAKOTA – MEDICAID

www.nd.gov/dhs/services/medicalserv/medicaid/

1-800-755-2604

OKLAHOMA – MEDICAID

www.insureoklahoma.org

1-888-365-3742

OREGON – MEDICAID AND CHIP

Medicaid & CHIP: www.oregonhealthy kids.gov

Medicaid & CHIP : 1-877-314-5678

PENNSYLVANIA – MEDICAID

www.dpw.state.pa.us/partnersproviders/

medicalassistance/doingbusiness/003670053.htm

1-800-644-7730

RHODE ISLAND – MEDICAID

www.dhs.ri.gov

401-462-5300

SOUTH CAROLINA – MEDICAID

www.scdhhs.gov

1-888-549-0820

TEXAS – MEDICAID

www.gethipptexas.com/

1-800-440-0493

UTAH – MEDICAID

http://health.utah.gov/medicaid/

1-866-435-7414

VERMONT– MEDICAID

http://ovha.vermont.gov/

1-800-250-8427

VIRGINIA – MEDICAID AND CHIP

Medicaid: www.dmas.virginia.gov/rcp-HIPP.htm

Medicaid: 1-800-432-5924

CHIP: www.famis.org/

CHIP: 1-866-873-2647

WASHINGTON – MEDICAID

http://hrsa.dshs.wa.gov/premiumpymt/Apply.shtm

1-877-543-7669

WEST VIRGINIA – MEDICAID

www.wvrecovery.com/hipp.htm

304-342-1604

WISCONSIN – MEDICAID

http://dhs.wisconsin.gov/medicaid/publications/p-10095.htm

1-800-362-3002

WYOMING – MEDICAID

www.health.wyo.gov/health carefin/index.html

307-777-7531

U.S. DEPARTMENT OF LABOR

Employee Benefits Security Services

www.dol.gov/ebsa or 1-866-444-EBSA (3272)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Administration Centers for Medicare & Medicaid

www.cms.hhs.gov or 1-877-267-2323, Ext. 61565

HIPAA NOTICE OF PRIVACY PRACTICES

This describes how medical information about you may be used and

disclosed and how you can get access to this information. Please review it

carefully.

Health Information Privacy

This Notice is required by the Health Insurance Portability and

Accountability Act of 1996 (“HIPAA”) and is intended to describe how

the Seattle University health plan will protect your health information with

respect to its self-insured health benefits. References below to Health Plan

shall mean the medical, dental and health flexible spending account

benefits provided by the Health Plan.

“Health information” for this purpose means information that identifies you

and either relates to your physical or mental health condition, or relates

to the payment of your health care expenses. This individually identifiable

health information is known as “protected health information” (“PHI”). Your

PHI will not be used or disclosed without a written authorization from you,

except as described in this Notice or as otherwise permitted by federal or

state health information privacy laws.

Health Plan Privacy Obligations

The Health Plan is required by law to:

• y Make sure that health information that identifies you is kept private;

• y Give you this Notice of its legal duties and privacy practices with

respect to health information about you; and

• y Follow the terms of the Notice that are in effect.

How the Health Plan May Use and Disclose Health Information

about You

The Health Plan may use health information or disclose it to others for a

number of different reasons. The following are the different ways that the

Health Plan may use and disclose your PHI without your authorization:

• yFor Treatment. The Health Plan may disclose your PHI to a health

care provider who provides, coordinates or manages health care

treatment on your behalf. For example, if you are unable to provide

your medical history as a result of an accident, the Health Plan may

advise an emergency room physician about the different medications

that you may have been prescribed.

• yFor Payment. The Health Plan may use and disclose your PHI

so claims for health care treatment, services, and supplies that you

receive from health care providers may be paid according to the

Health Plan’s terms. The Health Plan may also use your PHI for

billing, reviews of health care services received, and subrogation. For

example, the Health Plan may tell a doctor or hospital whether you

are eligible for coverage or what percentage of the bill will be paid

by the Health Plan.

• yFor Health Care Operations. The Health Plan may use and

disclose your PHI to enable it to operate more efficiently or to make

certain that all of its participants receive the appropriate health

benefits. For example, the Health Plan may use your PHI for case

management, to refer individuals to disease management programs,

for underwriting, premium rating, activities relating to the creation,


enewal or replacement of a contract of health insurance or health benefits, to

arrange for medical reviews, or to perform population-based studies designed to

reduce health care costs. In addition, the Health Plan may use or disclose your PHI

to conduct compliance reviews, audits, legal reviews, actuarial studies, and/or for

fraud and abuse detection. The Health Plan may also combine health information

about participants and disclose it to Seattle University in a non-identifiable,

summary fashion so that Seattle University can decide, for example, what types

of coverage the Health Plan should provide. The Health Plan may also remove

information that identifies you from health information that is disclosed to Seattle

University so that the health information that is used by Seattle University does not

identify the specific Health Plan participants.

• yTo The Plan Sponsor. The Health Plan is sponsored by Seattle University. The

Health Plan may disclose your PHI to designated personnel at Seattle University

so that they can carry out related administrative functions, including the uses and

disclosures described in this Notice. Such disclosures will be made only to the

individuals authorized to receive such information under the Health Plan. These

individuals will protect the privacy of your health information and ensure that it is

used only as described in this Notice or as permitted by law. Unless authorized

by you in writing, your health information: (1) may not be disclosed by the Health

Plan to any other employee or department of Seattle University and (2) will not be

used by Seattle University for any employment-related actions or decisions, or in

connection with any other employee benefit plans sponsored by Seattle University.

• y To a Business Associate. Certain services are provided to the Health Plan by

third-party administrators known as “business associates.” For example, the Health

Plan may place information about your health care treatment into an electronic

claims processing system maintained by a business associate so that your claim

may be paid. In so doing, the Health Plan will disclose your PHI to its business

associates so that the business associates can perform their claims payment

functions. However, the Health Plan will require its business associates, through

written agreements, to appropriately safeguard your health information.

• yFor Treatment Alternatives. The Health Plan may use and disclose your PHI

to tell you about possible treatment options or health care alternatives that may be

of interest to you.

• yFor Health-Related Benefits and Services. The Health Plan may use and

disclose your PHI to tell you about health-related benefits or services that may be of

interest to you.

• yTo Individuals Involved in Your Care or Payment of Your Care. The

Health Plan may disclose PHI to a close friend or family member involved in or

who helps pay for your health care. The Health Plan may also advise a family

member or close friend about your condition, your location (for example, that you

are in the hospital), or death, unless other laws would prohibit such disclosures.

• yAs Required by Law. The Health Plan will disclose your PHI when required to

do so by federal, state, or local law, including those laws that require the reporting

of certain types of wounds, illnesses or physical injuries.

Special Use and Disclosure Situations

The Health Plan may also use or disclose your PHI without your authorization under the

following circumstances:

• yLawsuits and Disputes. If you become involved in a lawsuit or other

legal action, the Health Plan may disclose your PHI in response to a court or

administrative order, a subpoena, warrant, discovery request, or other forms of

lawful due process.

• yLaw Enforcement. The Health Plan may release your PHI if asked to do so by a

law enforcement official, for example, to report child abuse, to identify or locate a

suspect, material witness, missing person or to report a crime, the crime’s location

or victims, or the identity, description, or location of the person who committed the

crime.

• yWorkers’ Compensation. The Health Plan may disclose your PHI to the extent

authorized by and to the extent necessary to comply with workers’ compensation

laws and other similar programs.


• yMilitary and Veterans. If you are or become a member of the U.S.

armed forces, the Health Plan may release medical information about

you as deemed necessary by military command authorities.

• yTo Avert Serious Threat to Health or Safety. The Health Plan

may use and disclose your PHI when necessary to prevent a serious

threat to your health and safety, or the health and safety of the public

or another person.

• yPublic Health Risks. The Health Plan may disclose health

information about you for public health activities. These activities

include preventing or controlling disease, injury or disability; reporting

births and deaths; reporting child abuse or neglect; or reporting

reactions to medications or problems with medical products, or to

notify people of recalls of products they have been using.

• yHealth Oversight Activities. The Health Plan may disclose your

PHI to a health oversight agency for audits, investigations, inspections,

and licensure necessary for the government to monitor the health care

system and government programs.

• yResearch. Under certain limited circumstances, the Health Plan may

use and disclose your PHI for medical research purposes.

• yNational Security, Intelligence Activities, and Protective

Services. The Health Plan may release your PHI to authorized

federal officials: (1) for intelligence, counterintelligence, and other

national security activities authorized by law, and (2) to enable them

to provide protection to the members of the U.S. government or foreign

heads of state, or to conduct special investigations.

• yOrgan and Tissue Donation. If you are an organ donor, the

Health Plan may release medical information to organizations that

handle organ procurement or organ, eye, or tissue transplantation, or

to an organ donation bank to facilitate organ or tissue donation and

transplantation.

• yCoroners, Medical Examiners, and Funeral Directors. The

Health Plan may release your PHI to a coroner or medical examiner.

This may be necessary, for example, to identify a deceased person

or to determine the cause of death. The Health Plan may also release

your PHI to a funeral director, as necessary, to carry out his/her

responsibilities.

Your Rights Regarding Your Health Information

You have the following rights regarding the health information that the

Health Plan maintains about you:

• yRight to Inspect and Copy Your Personal Health

Information. You have the right to inspect and copy your PHI that

is maintained in a “designated record set” for so long as the Health

Plan maintains your PHI. A “designated record set” includes medical

information about eligibility, enrollment, claim and appeal records,

and medical and billing records maintained by the Health Plan, but

does not include psychotherapy notes, information intended for use

in a civil, criminal or administrative proceeding, or information that is

otherwise prohibited by law.

• yTo inspect and copy health information maintained by

the Health Plan, submit your request in writing to the

Privacy Official. The Health Plan may charge a fee for the cost of

copying and/or mailing your request. The Health Plan must act upon

your request for access no later than 30 days after receipt (60 days

if the information is maintained off-site). A single, 30-day extension is

allowed if the Health Plan is unable to comply by the initial deadline.

In limited circumstances, the Health Plan may deny your request to

inspect and copy your PHI. Generally, if you are denied access to

your health information, you will be informed as to the reasons for the

denial, and of your right to request a review of the denial.

YOUR 2013 GUIDE TO YOUR BENEFITS ||| 21

• yYou may request an electronic copy of your health

information if it is maintained in an electronic health

record. You may also request that such electronic health information

be sent to another entity or person, so long as that request is clear,

conspicuous and specific. Any charge that is assessed to you for these

copies, if any must be reasonable and based on the Health Plan’s cost.

• yRight to Amend Your Personal Health Information. If you

feel that the health information that the Health Plan has about you is

incorrect or incomplete, you may ask the Health Plan to amend it. You

have the right to request an amendment for so long as the Health Plan

maintains your PHI in a designated record set.

• yTo request an amendment, send a detailed request in

writing to the Privacy Official. You must provide the reason(s)

to support your request. The Health Plan may deny your request if you

ask the Health Plan to amend health information that was: (1) accurate

and complete; (2) not created by the Health Plan; (3) not part of the

health information kept by or for the Health Plan; or (4) not information

that you would be permitted to inspect and copy. The Health Plan has

60 days after the request is received to act on the request. A single,

30-day extension is allowed if the Health Plan cannot comply by the

initial deadline. If the request is denied, in whole or in part, the Health

Plan will provide you with a written denial that explains the basis for

the denial. You may then submit a written statement disagreeing with

the denial and, if permitted under HIPAA, have that statement included

with any future disclosures of your PHI.

• yRight to an Accounting of Disclosures. You have the right to

request an “accounting of disclosures” of your PHI. This is a list of

disclosures of your PHI that the Health Plan has made to others for the

six (6) year period prior to the request, except for those disclosures

necessary to carry out treatment, payment, or health care operations,

disclosures previously made to you, disclosures that occurred prior

to the date on which the accounting is requested, or in certain other

situations described under HIPAA. To request an accounting of

disclosures, submit your request in writing to the Privacy Official. Your

request must state a time period, which may not be longer than six (6)

years prior to the date the accounting was requested. If the accounting

cannot be provided within 60 days, an additional 30 days is allowed

if the Health Plan provides you with a written statement of the reasons

for the delay and the date by when the accounting will be provided.

If you request more than one accounting within a 12-month period,

the Health Plan will charge a reasonable, cost-based fee for each

subsequent accounting.

• yRight to Request Restrictions. You have the right to request

a restriction on the health information that the Health Plan uses or

discloses about you for treatment, payment, or health care operations.

You also have the right to request that the Health Plan limits the

individuals (for example, family members) to whom the Health Plan

discloses health information about you. For example, you could ask

that the Health Plan not use or disclose information about a surgical

procedure that you had. While the Health Plan will consider your

request, it is not required to agree to it except in those situations

where the requested restriction relates to the disclosure to the Plan for

purposes of carrying out payment or health care operations (and not

for treatment) and the Protected Health Information pertains solely to a

health care item or service that was paid for out of pocket in full. If the

Health Plan agrees to the restriction, it will comply with your request

until such time as the Health Plan provides written notice to you of its

intent to no longer agree to such restriction, or unless such disclosure is

required by law.


To request a restriction or limitation, make your request in writing to the Privacy

Official. In your request, you must state: (1) what information you want to limit; (2)

whether you want to limit the Health Plan’s use, disclosure, or both; and (3) to whom

you want the limit(s) to apply. Note: the Health Plan is not required to agree to your

request.

• yRight to Request Confidential Communications. You have the right to

request that the Health Plan communicates with you about health matters using

alternative means or at alternative locations. For example, you can ask that the

Health Plan send your explanation of benefits (“EOB”) forms about your benefit

claims to a specified address. To request confidential communications, make your

request in writing to the Privacy Official. The Health Plan will make every attempt to

accommodate all reasonable requests. Your request must specify how or where you

want to be contacted.

• yState Privacy Rights. You may have additional privacy rights under state

laws, including rights in connection with mental health and psychotherapy reports,

pregnancy, HIV/AIDS-related illnesses, and the health treatment of minors.

• yRight to a Paper Copy of this Notice. You have the right to a paper copy of

this Notice upon request. This right applies even if you have previously agreed to

accept this Notice electronically. You may write to the Privacy Official to request a

written copy of this Notice at any time.

Changes to this Privacy Notice

The Health Plan reserves the right to change this Notice at any time and from time to

time, and to make the revised or changed Notice effective for health information that the

Health Plan already has about you, as well as any information that the Health Plan may

receive in the future. The revised Notice will be provided to you in the same manner as this

Notice, or electronically if you have consented to receive the Notice electronically.

Complaints

If you believe that your health information privacy rights as described under this Notice

have been violated, you may file a written complaint with the Health Plan by contacting

the person listed at the address under “Contact Information”.

You may also file a written complaint directly with the regional office of the U.S.

Department of Health and Human Services, Office for Civil Rights.

The complaint should generally be filed within 180 days of when the act or omission

complained of occurred. Note: You will not be penalized or retaliated against for filing

a complaint.

Other Uses and Disclosures of Health Information

Other uses and disclosures of health information not covered by this Notice or by the laws

that apply to the Health Plan will be made only with your written authorization. If you

authorize the Health Plan to use or disclose your PHI, you may revoke the authorization,

in writing, at any time. If you revoke your authorization, the Health Plan will no longer use

or disclose your PHI for the reasons covered by your written authorization; however, the

Health Plan will not reverse any uses or disclosures already made in reliance on your prior

authorization. The Health Plan will notify you in the event that there is a breach involving

unsecured Protected Health Information.

Contact Information

To receive more information about the Health Plan’s privacy practices or your rights, or if

you have any questions about this Notice, please contact the Health Plan at the following

address: Seattle University, 206-296-5891


EMPLOYEE RIGHTS AND

RESPONSIBILITIES UNDER THE FAMILY

AND MEDICAL LEAVE ACT

Basic Leave Entitlement

FMLA requires covered employers to provide up to 12 weeks of unpaid,

job-protected leave to eligible employees for the following reasons:

• y For incapacity due to pregnancy, prenatal medical care or child birth;

• y To care for the employee’s child after birth, or placement for adoption

or foster care;

• y To care for the employee’s spouse, son or daughter, or parent, who

has a serious health condition; or

• y For a serious health condition that makes the employee unable to

perform the employee’s job.

Military Family Leave Entitlements

Eligible employees with a spouse, son, daughter, or parent on active duty or

call to active duty status in the National Guard or Reserves in support of a

contingency operation may use their 12-week leave entitlement to address

certain qualifying exigencies. Qualifying exigencies may include attending

certain military events, arranging for alternative childcare, addressing

certain financial and legal arrangements, attending certain counseling

sessions, and attending post-deployment reintegration briefings.

FMLA also includes a special leave entitlement that permits eligible

employees to take up to 26 weeks of leave to care for a covered service

member during a single 12-month period. A covered service member is a

current member of the Armed Forces, including a member of the National

Guard or Reserves, who has a serious injury or illness incurred in the line of

duty on active duty that may render the service member medically unfit to

perform his or her duties for which the service member is undergoing medical

treatment, recuperation, or therapy; or is in outpatient status; or is on the

temporary disability retired list.

Benefits and Protections

During FMLA leave, the employer must maintain the employee’s health

coverage under any “group health plan” on the same terms as if the

employee had continued to work. Upon return from FMLA leave, most

employees must be restored to their original or equivalent positions with

equivalent pay, benefits, and other employment terms.

Use of FMLA leave cannot result in the loss of any employment benefit that

accrued prior to the start of an employee’s leave.

Eligibility Requirements

Employees are eligible if they have worked for a covered employer for at

least one year, for 1,250 hours over the previous 12 months.

Definition of Serious Health Condition

A serious health condition is an illness, injury, impairment, or physical or

mental condition that involves either an overnight stay in a medical care

facility, or continuing treatment by a health care provider for a condition

that either prevents the employee from performing the functions of the

employee’s job, or prevents the qualified family member from participating

in school or other daily activities.

Subject to certain conditions, the continuing treatment requirement may

be met by a period of incapacity of more than three consecutive calendar

days combined with at least two visits to a health care provider or one visit

and a regimen of continuing treatment, or incapacity due to pregnancy,

or incapacity due to a chronic condition. Other conditions may meet the

definition of continuing treatment.

YOUR 2013 GUIDE TO YOUR BENEFITS ||| 23

Use of Leave

An employee does not need to use this leave entitlement in one block.

Leave can be taken intermittently or on a reduced leave schedule when

medically necessary. Employees must make reasonable efforts to schedule

leave for planned medical treatment so as not to unduly disrupt the

employer’s operations. Leave due to qualifying exigencies may also be

taken on an intermittent basis.

Substitution of Paid Leave for Unpaid Leave

Employees may choose or employers may require use of accrued paid

leave while taking FMLA leave. In order to use paid leave for FMLA leave,

employees must comply with the employer’s normal paid leave policies.

Employee Responsibilities

Employees must provide 30 days advance notice of the need to take FMLA

leave when the need is foreseeable. When 30 days notice is not possible,

the employee must provide notice as soon as practicable and generally

must comply with an employer’s normal call-in procedures.

Employees must provide sufficient information for the employer to determine

if the leave may qualify for FMLA protection and the anticipated timing and

duration of the leave. Sufficient information may include that the employee

is unable to perform job functions; the family member is unable to perform

daily activities, the need for hospitalization or continuing treatment by a

health care provider, or circumstances supporting the need for military family

leave. Employees also must inform the employer if the requested leave is for a

reason for which FMLA leave was previously taken or certified.

Employees also may be required to provide a certification and periodic

recertification supporting the need for leave.

Employer Responsibilities

Covered employers must inform employees requesting leave whether they

are eligible under FMLA. If they are, the notice must specify any additional

information required as well as the employees’ rights and responsibilities. If

they are not eligible, the employer must provide a reason for the ineligibility.

Covered employers must inform employees if leave will be designated as

FMLA-protected and the amount of leave counted against the employee’s

leave entitlement. If the employer determines that the leave is not FMLAprotected,

the employer must notify the employee.

Unlawful Acts by Employers

FMLA makes it unlawful for any employer to:

• y Interfere with, restrain, or deny the exercise of any right provided

under FMLA;

• y Discharge or discriminate against any person for opposing any

practice made unlawful by FMLA or for involvement in any proceeding

under or relating to FMLA.

Enforcement

An employee may file a complaint with the U.S. Department of Labor or

may bring a private lawsuit against an employer.

FMLA does not affect any Federal or State law prohibiting discrimination,

or supersede any State or local law or collective bargaining agreement

which provides greater family or medical leave rights.

FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers

to post the text of this notice. Regulations 29 C.F.R. § 825.300(a) may

require additional disclosures.

For Additional Information

1-866-4US-WAGE

(1-866-487-9243)

TTY: 1-877-889-5627

www.wagehour.dol.gov

U.S. Department of Labor

Employment Standards Admin

Wage and Hour Division

WHD Public

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