YOUR 2013 GUIDE
TO YOUR BENEFITS
JANUARY 1 – DECEMBER 31, 2013
MAKE THE MOST OF
• y November 1 – Open Enrollment
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-
• 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-
• y November 15 – Brown Bag
Seminar: 11:30 a.m. at PIGT Pigott
• y November 27 – Health Screenings:
8:00 a.m. – 2:30 p.m. at Student
Center #160 – LeRoux Conference
• y November 28 – Still have questions?
Come visit Human Resources for oneon-one
• y November 30 – Open Enrollment
• 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
TABLE OF CONTENTS
3 Common Terms
4 Medical and Prescription Drugs
10 Flexible Spending Accounts
11 Life and Disability
12 WorkLife Reources/EAP
12 2013 Benefit Program Costs
14 Required Notices
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.
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
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.
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
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/
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
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.
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.
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
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.
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
Employee Only $3,250 $750 $2,500
Employee Plus One or
If you are 55 or older, you may add a “catch-up” contribution of $1,000.
$6,450 $1,500 $4,950
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
Why Enroll in an HSA
An HSA helps you set aside tax-advantaged dollars to meet future health
• 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
PREMERA BLUE CROSS
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
Well-Baby Exams 100% 60% after
Adult Physical Exam 100% 60% after
Well-Women Exams/Screenings 100% 60% after
Immunizations 100% 60% after
Doctor Office Visit $20 then 100% 60% after
Urgent Care $20 then 100% 60% after
Inpatient Hospital Services
Outpatient Hospital Services
(copay waived if admitted)
$100 copay, then deductible/
100% 50% after
100% 50% after
100% 50% after
100% 50% after
$20 then 100%
$20 then 100%
$20 then 100%
$100 copay for
GHC or non-GHC
Ambulance 80% after deductible 100%
Prescription Drugs (retail)
Generic $10 90% after deductible $10
Preferred Brand $25 $25
Non-Preferred Brand $50 N/A
Prescription Drugs (mail-order)
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:
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
• 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.
YOUR 2013 GUIDE TO YOUR BENEFITS ||| 9
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.
Benefit In Network Out-of-Network
Exam $20 copay Reimbursed up to $50, after $20 copay
$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
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).
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
$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%
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).
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
• 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.
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.
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.
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.
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
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.
Annual Rate of Pay Premera PPO Plan Premera HSA Plan Group Health HMO
$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
Benefit Contact Group Number Website Phone Number
Health Savings Account
Fidelity N/A www.netbenefits.fidelity.com 1-800-343-0860
387 www.deltadentalwa.com 1-800-554-1907
623-5178 www.vsp.com 1-800-877-7195
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
Ruth Sanoy N/A N/A 206-296-5894
The Women’s Health and Cancer Right Act of 1998 requires medical plans
that offer mastectomy benefits to also provide coverage for reconstructive
Coverage extends to:
• y Reconstructive surgery of the breast on which the mastectomy is
• 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
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.
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).
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
• 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
• 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
• 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
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
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
ALABAMA – MEDICAID
ALASKA – MEDICAID
(Outside of Anchorage): 1-888-318-8890
ARIZONA – CHIP
ARKANSAS – CHIP
CALIFORNIA – MEDICAID
MEDICAID AND CHIP
CHIP Phone: 303-866-3243
FLORIDA – MEDICAID
GEORGIA – MEDICAID
(Click on Programs, then Medicaid)
IDAHO – MEDICAID AND CHIP
INDIANA – MEDICAID
IOWA – MEDICAID
KANSAS – MEDICAID
KENTUCKY – MEDICAID
LOUISIANA – MEDICAID
MAINE – MEDICAID
MEDICAID AND CHIP
Medicaid & CHIP: www.mass.gov/
Medicaid & CHIP: 1-800-462-1120
MINNESOTA – MEDICAID
(Click on Health Care, then
MISSOURI – MEDICAID
MONTANA – MEDICAID
NEBRASKA – MEDICAID
NEVADA – MEDICAID AND CHIP
NEW HAMPSHIRE – MEDICAID
1-800-852-3345 x 5254
NEW JERSEY – MEDICAID
NEW MEXICO –
MEDICAID AND CHIP
(Click on Insure New Mexico)
YOUR 2013 GUIDE TO YOUR BENEFITS ||| 19
NEW YORK – MEDICAID
NORTH CAROLINA – MEDICAID
NORTH DAKOTA – MEDICAID
OKLAHOMA – MEDICAID
OREGON – MEDICAID AND CHIP
Medicaid & CHIP: www.oregonhealthy kids.gov
Medicaid & CHIP : 1-877-314-5678
PENNSYLVANIA – MEDICAID
RHODE ISLAND – MEDICAID
SOUTH CAROLINA – MEDICAID
TEXAS – MEDICAID
UTAH – MEDICAID
VIRGINIA – MEDICAID AND CHIP
WASHINGTON – MEDICAID
WEST VIRGINIA – MEDICAID
WISCONSIN – MEDICAID
WYOMING – MEDICAID
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
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
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
• 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
• 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
• 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
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
• 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
• 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.
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
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.
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.
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.
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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.
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.
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
• 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.
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
U.S. Department of Labor
Employment Standards Admin
Wage and Hour Division