- Medicare Plan D
- Notice of Privacy Practices
- Premium Assistance Under Medicaid and CHIP
- Workers Compensation
You and/or each of your covered dependents may qualify to continue your group health care coverage that would otherwise end due to any of the following qualifying events:
- Termination of employment or through retirement for any reason other than your Gross Misconduct
- A loss of benefits due to a reduction in your work hours; or
- For your surviving spouse (and/or children) if coverage would otherwise end due to your death; or
- For your former spouse (and any children) if coverage would otherwise end due to divorce or legal separation; or
- For your spouse and/or children, if coverage would otherwise end due to your reduction in hours
- For your spouse and/or children if coverage would otherwise end due to your Medicare entitlement
- For your child if coverage would otherwise end because the child ceased to be a dependent
COBRA for employees, their spouse, or children must be paid through Automated Clearing House (ACH). The monthly premium is deducted from your personal checking account on the last day of the month proceeding the month of coverage. A voided check is required for set up.
Please note that Domestic Partners or non-qualified dependents do not qualify for COBRA coverage.
You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child losing eligibility for coverage as a dependent child), you must give written notice to the Plan Administrator, Audrey Martin, in the Benefits Office within 60 days after the qualifying event occurs.
How is COBRA Coverage Provided?
Once the Benefits Office receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended.
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. You must make sure that the Plan Administrator is notified, in person, of the determination within 14 days of receiving the Social Security Administration determination letter and before the end of the 18-month period of COBRA continuation coverage. The premium during the 11- month disability extension may increase to 150% of the regular COBRA premium. If the qualified beneficiary is determined by Social Security Administration to no longer be disabled, you must notify the Northshore School District Human Resources Plan Administrator of that fact, in writing, within 30 days after Social Security Administration’s determination.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan Administrator. This extension is available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies or gets divorced or legally separated. You must make sure that the Plan Administrator is notified of the second qualifying event, in person, within 60 days of the second qualifying event. The notice must be made in writing to:
Human Resources, Benefits Office
Northshore School District
3330 Monte Villa Parkway
Bothell, WA 98021-8972
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified above. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa . (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
HIPAA amended the Employee Retirement Income Security Act (ERISA), to provide new rights and protections for participants and beneficiaries in group health plans. Understanding this amendment is important to your decisions about future health coverage. HIPAA contains protections both for health coverage offered in connection with employment (group health plans) and for individual insurance policies sold by insurance companies (individual policies).
If you find a new job that offers health coverage, or if you are eligible for coverage under a family member's employment-based plan, HIPAA includes protections for coverage under group health plans that:
- Limit exclusions for preexisting conditions
- Prohibit discrimination against employees and dependents based on their health status
- Allow a special opportunity to enroll in a new plan to individuals in certain circumstances
If you choose to apply for an individual policy for yourself or your family, HIPAA includes protections for individual policies that guarantee access to individual policies for people who qualify and guarantee renewability of individual policies.
Congress recognized the need for national patient record privacy standards in 1996 when they enacted the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The law included provisions designed to save money for health care businesses by encouraging electronic transactions, but it also required safeguards to protect the security and confidentiality of that information.
Special Enrollment rights under HIPAA allow for eligible employees or their dependents to apply for NSD's group health coverage. All of the following must apply for an individual to be considered under HIPAA Special Enrollment. Otherwise, the next available opportunity to enroll is during the regular Open Enrollment period from August 10 through September 10.
- At the time coverage was declined for the individual(s), a Waiver of Insurance form was completed listing the indvidual(s) who were not being covered under NSD's group insurance plan. (Having other individual insurance coverage does not qualify as a reason for declining group health coverage. Loss of individual coverage does not qualify for Special Enrollment.).
- The individual listed on the Waiver of Insurance form had other credible group coverage and lost it through no fault of their own. A Certificate of Insurance showing dates/reason for loss of coverage is provided.
- Enrollment requested within 30 days of losing other credible group coverage.
This notice has information about your current prescription drug coverage with Northshore Medical Plans 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. If you are considering joining, 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. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
1. 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.
2. Regence Blue Shield and Group Health has determined that the prescription drug coverage offered by them is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You 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 to December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Northshore School District coverage will not be affected. You can keep your current coverage if you elect Part D and this plan will coordinate with Part D coverage.
If you do decide to join a Medicare drug plan and drop your current Regence Blue Shield or Group Health coverage, be aware that you and your dependents will be able to get this coverage back. Although, a member under the Northshore School District Agreement must meet eligibility requirements in order to re-enroll.
When Will You Pay a Higher Premium (Penalty) To Join a Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Regence Blue Shield or Group Health 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 creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare 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.
For More Information
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. 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:
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
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
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).
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
As a participant in the Northshore School District Plan (the “Plan”), you are eligible for certain health care benefits. In the course of providing these benefits to you, the Plan may receive and maintain some of your medical information. Federal law requires that the Plan protect the privacy of, generally, medical information that identifies you and relates to your past, present or future health or condition, the provision of health care to you, or the payment for health care received by you (“protected health information” or “PHI”). The Plan may hire other companies (“Business Associates”) to help provide health care benefits to you. These Business Associates may also receive and maintain your medical information.
The Plan is required to abide by the terms of the Notice currently in effect.
The Plan may change its privacy practices and the terms of this Notice at any time. Changes will be effective for all of your medical information received or created by the Plan. If the Plan changes its policies regarding the protection of your medical information, the Plan will mail you a new notice of privacy practices that incorporates any changes within 60 days. The Plan will also post a new notice on its internet website.
How The Plan May Use And Disclose Your Medical Information
The Plan may use and disclose your medical information without your written permission for the following purposes: For treatment. While the Plan does not directly participate in decisions regarding your health treatment, the Plan may disclose medical information it has created or received for treatment purposes. For example, the Plan may disclose your medical information to your doctor, at the doctor's request, for his or her treatment of you.
The Plan or one of its Business Associates may use or disclose your medical information to pay claims for medical services provided to you or to provide eligibility information to your doctor when you receive medical treatment.
For health care operations
The Plan may provide your medical information to our accountants, attorneys, consultants, and others in order to make sure we are complying with federal law. Also, your medical information may be used or disclosed to assess the quality of health care that you receive or to assist the Plan in the management of its performance of administrative activities.
To you, your personal representative, or others involved in your healthcare
The Plan may provide your medical information to you and your legal representative. The Plan may also provide medical information to a person, including family members, other relatives, friends or others identified by you and acting on your behalf, so long as you do not object and the information is directly relevant to such person's involvement in your health care. For this purpose, a person acts on your behalf by being involved in the provision and/or payment of your health care.
As required by law
For example, the Plan may disclose your medical information to comply with workers' compensation laws or other similar laws. To Business Associates. The Plan may disclose your medical information to its Business Associates so that they may perform the services that the Plan has asked them to perform. The Plan requires that these entities appropriately safeguard your medical information.
For health-related benefits
The Plan or one of its Business Associates may contact you about treatment alternatives or other health benefits or services that may be of interest to you.
For other uses and disclosures permitted by law such as
- To public health authorities for public health purposes (e.g. the reporting of communicable diseases);
- To state agencies handling cases of abuse, neglect, or domestic violence;
- To a government agency authorized to oversee the health care system or government programs (e.g. determining eligibility for public benefits);
- To law enforcement officials for limited law enforcement purposes (e.g. to locate a missing person or suspect);
- To a coroner, medical examiner, or funeral director about a deceased person (e.g. to identify a person);
- To an organ procurement organization under limited circumstances;
- For research purposes in limited circumstances (e.g. if identifying information is removed or a research board has approved the use of the information);
- To avert a serious threat to your health or safety or the health or safety of others;
- To military authorities if you are a member of the armed forces or a veteran of the armed forces;
- To federal officials for lawful intelligence, counterintelligence, and other national security purposes;
- To an executor or administrator of your estate; and
- To any other persons and/or entities authorized under law to receive medical information.
For any other use or disclosure of your medical information, the Plan must have your written authorization. You may cancel your written authorization for the use and disclosure of any or all of your medical information, unless the Plan has taken action in reliance on your permission.
Some uses and disclosures that require your authorization are those with respect to:
- Psychotherapy notes, except: o to carry out the following treatment, payment, or health care operations:
- use by the originator of the psychotherapy notes for treatment;
- use or disclosure by the provider for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or
- use or disclosure by the Plan to defend itself in a legal action or other proceeding brought by the individual; or o with respect to a use or disclosure that is:
- required by the Secretary to investigate or determine the Plan's compliance;
- permitted to the extent that such use or disclosure is required by law and the use or disclosure complies with and is limited to the relevant requirements of such law and in accordance with HIPAA;
- to a health oversight agency for oversight activities authorized by law with respect to the oversight of the originator of the psychotherapy notes;
- to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law; or
- as necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
- Marketing except if the communication is in the form of:
- a face-to-face communication made by a Plan to an individual; or
- a promotional gift of nominal value provided by the Plan. If the marketing involves financial remuneration, to the Plan from a third party, the authorization must state that such remuneration is involved.
- Sale of PHI.
The Plan is prohibited from using or disclosing PHI that is genetic information of an individual for underwriting purposes.
The Plan is required by law to maintain the privacy of PHI, to provide individuals with notice of its legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI.
You may make a written request to the Plan to do one or more of the following concerning your medical information received or created by the Plan and/or the Plan's Business Associates:
- The right to request restrictions on certain uses and disclosures of medical information; however, the Plan is not required to agree to such request unless:
- the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and
- the PHI pertains solely to a health care item or service for which the individual, or person other than the health plan on behalf of the individual, has paid the Plan in full.
- The right to receive confidential communications of medical information by alternative means or at alternative locations.
- The right to inspect and copy medical information.
- The right to amend medical information.
- The right to receive an accounting of disclosures of medical information.
- The right, even if you have agreed to receive this notice electronically, to obtain a paper copy of this from the Plan upon request.
Although the Plan will utilize its best efforts to comply with your request, the Plan may legally deny your request under certain circumstances. The Plan will notify you of the reason for the denial and you will get a chance to respond. The Plan may not deny a request to communicate with you in confidence by a different means or location if the current means or location used by the Plan endangers you. The Plan may, however, request payment for any additional expenses it incurs to comply with your request. Your request to communicate by a different means or location must be in writing, include a statement that disclosure of all or part of the medical information by the current means could endanger you, specifically state the different means or location by which you would like the Plan to communicate with you, and continue to allow the Plan to pay claims.
If you feel as if your privacy rights have been violated, you may file a written complaint with:
Human Resources Benefits Office
Northshore School District
3330 Monte Villa Parkway
Bothell, WA 98021-8972
You may also send a written or electronic complaint to the Secretary of the Department of Health and Human Services. The complaint must state the name of the entity that is the subject of the complaint and describe the act or omissions believed to be in violation of law. A complaint must be filed within 180 days of when you knew or should have known that the act or omission complained of occurred. The Plan may not retaliate against you if you file a complaint.
If you would like more information about this Notice, please contact Lisa McLean at (425) 408-7611.
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, 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, 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, ask your state if it has a program that might help you pay the premiums for an employer sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov call 1-866-444-EBSA (3272).
You may be eligible for assistance paying your employer health plan premiums. Residents of Washington State can learn more by visiting:
Washington State Health Care Authority
Phone: 1-800-562-3022 ext. 15473
To see information for other states, visit:
Employee Benefits Security Administration
Centers for Medicare & Medicaid Services
1-877-267-2323, Menu Option 4, Ext. 61565
If a job injury occurs
Your employer is self-insured. You are entitled to all of the benefits required by the state of Washington’s workers’ compensation (industrial insurance) laws. These benefits include medical treatment and partial wage replacement if your work-related injury or disease requires you to miss work. Compliance with these laws is regulated by the Department of Labor & Industries (L&I).
What you should do
Report your injury. If you are injured, no matter how minor the injury seems, contact:
Get medical care. The first time you see a doctor, you may choose any health-care provider who is qualified to treat your injury. For ongoing care, you must be treated by a doctor in the L&I medical network. (Find network providers at www.FindADoc.Lni.wa.gov.)
Qualified health-care providers include: medical, osteopathic, chiropractic, naturopathic and podiatric physicians; dentists; optometrists; ophthalmologists; physician assistants; and advanced registered nurse practitioners.
File your claim as soon as possible. For an on-the-job injury, you must file a claim with your employer within one year after the day the injury occurred. For an occupational disease, you must file a claim within two years following the date you are advised by a health-care provider in writing that your condition is work related.