Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’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 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 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 askebsa.dol.gov or call 1-866-444-EBSA.

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2021. Contact your State for more information on eligibility.

ALABAMA - Medicaid	NEVADA - Medicaid
Website: myalhipp.com Phone: (855) 692-5447	Website: dhs.iowa.gov/hawk-i Phone: (800) 257-8563
ALASKA - Medicaid	NEW JERSEY - Medicaid and CHIP
The AK Health Insurance Premium Payment Program Website: myakhipp.com Phone: (866) 251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: dhss.alaska.gov/dpa/Pages/medicaid/default.aspx	Medicaid website: state.nj.us/humanservices/dmahs/clients/medicaid Medicaid Phone: (609) 631-2392 CHIP website: njfamilycare.org/index.html CHIP Phone: (800) 701-0710
ARKANSAS - Medicaid	NEW YORK - Medicaid
Website: myarhipp.com Phone:(855) 692-7447	Website: health.ny.gov/health_care/medicaid Phone: (800) 541-2831
CALIFORNIA - Medicaid	NORTH CAROLINA - Medicaid
Health Insurance Premium Payment (HIPP) Program Website: dhcs.ca.gov/hipp Phone: (916) 445-8322 Email: hipp@dhcs.ca.gov	Website: medicaid.ncdhhs.gov Phone: (919) 855-4100
COLORADO - Medicaid and CHP+	NORTH DAKOTA - Medicaid
Health First Colorado & Child Health Plan Plus Website: healthfirstcolorado.com Phone: (800) 221-3943 | State Relay 711 CHP+: colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: (800) 359-1991 | State Relay 711 Health Insurance Buy-In Program (HIBI): colorado.gov/pacific/hcpf/health-insurance-buy-program HIBI Customer Service: (855) 692-6442	Website: nd.gov/dhs/services/medicalserv/medicaid Phone: (844) 854-4825
FLORIDA - Medicaid	OKLAHOMA - Medicaid and CHIP
Website: flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: (877) 357-3268	Website: insureoklahoma.org Phone: (888) 365-3742
GEORGIA - Medicaid	OREGON - Medicaid
Phone: (678) 564-1162 ext. 2131	Websites: healthcare.oregon.gov/Pages/index.aspx Phone: (800) 699-9075
INDIANA - Medicaid	PENNSYLVANIA - Medicaid
Healthy Indiana Plan for low-income adults 19-64 Website: in.gov/fssa/hip Phone: (877) 438-4479 All other Medicaid website: in.gov/medicaid Phone: (800) 457-4584	Phone: (800) 692-7462
IOWA - Medicaid and CHIP (Hawki)	RHODE ISLAND - Medicaid
Medicaid Website: dhs.iowa.gov/ime/members Medicaid Phone: (800) 338-8366 Hawki Website: dhs.iowa.gov/Hawki Hawki Phone: (800) 257-8563 HIPP Website: dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp HIPP Phone: (888) 346-9562	Phone: (855) 697-4347 or (401) 462-0311
KANSAS - Medicaid	SOUTH CAROLINA - Medicaid
Website: kancare.ks.gov Phone: (800) 792-4884	Phone: (888) 549-0820
KENTICKY - Medicaid	SOUTH DAKOTA - Medicaid
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: (855) 459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: kidshealth.ky.gov/Pages/index.aspx Phone: (877) 524-4718 Kentucky Medicaid Website: chfs.ky.gov	Phone: (888) 828-0059
LOUISIANA - Medicaid	TEXAS - Medicaid
Website: medicaid.la.gov or ldh.la.gov/lahipp Phone: (888) 342-6207 (Medicaid hotline) or (855) 618-5488 (LaHIPP)	Website: gethipptexas.com Phone: (800) 440-0493
MAINE - Medicaid	UTAH - Medicaid and CHIP
Enrollment Website: maine.gov/dhhs/ofi/applications-forms Phone: (800) 442-6003 | TTY: Maine relay 711 Phone: (800) 977-6740 | TTY: Maine relay 711	Medicaid website: medicaid.utah.gov CHIP website: health.utah.gov/chip Phone: (877) 543-7669
MASSACHUSETTS - Medicaid and CHIP	VERMONT - Medicaid
Website: mass.gov/eohhs/gov/departments/masshealth Phone: (800) 862-4840	Website: greenmountaincare.org Phone: (800) 250-8427
MINNESOTA - Medicaid	VIRGINIA - Medicaid and CHIP
Phone: (800) 657-3739	Websites: coverva.org/en/famis-select coverva.org/en/hipp Medicaid Phone: (800) 432-5924 CHIP Phone: (800) 432-5924
MISSOURI - Medicaid	WASHINGTON - Medicaid
Website: dss.mo.gov/mhd/participants/pages/hipp.htm Phone: (573) 751-2005	Website: hca.wa.gov Phone: (800) 562-3022
MONTANA - Medicaid	WEST VIRGINIA - Medicaid
Website: dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: (800) 694-3084	Website: mywvhipp.com Toll-free phone: (855) 699-8447
NEW HAPMSHIRE - Medicaid	WISCONSIN - Medicaid and CHIP
Website: dhhs.nh.gov/oii/hipp.htm Phone: (603) 271-5218 | Toll-free: (800) 852-3345, ext. 5218	Website: dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: (800) 362-3002
NEBRASKA - Medicaid	WYOMING - Medicaid
Website:ACCESSNebraska.ne.gov Phone: (855) 632-7633 Phone-Lincoln: (402) 473-7000 Phone-Omaha: (402) 595-1178	Website: health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility Phone: (800) 251-1269

• U.S. Department of Labor
  Employee Benefits Security Administration
  dol.gov/agencies/ebsa
  (866) 444-EBSA
• U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services
  cms.hhs.gov
  (877) 267-2323, Menu Option 4, Ext. 61565

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

This Notice is required by law.

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

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

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

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

Effective Date

The effective date of this Notice is October 1, 2021, and this notice replaces notices previously distributed to you.

Privacy Officer

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

Your Protected Health Information

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

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

Your Rights to privacy with respect to your PHI

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

Get a copy of health and claims records

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

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

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

You Have the Right to Amend Your PHI

If you think your health or claims records are incorrect or incomplete, you or your Personal Representative have the right to request that the Plan amend your PHI or a record about you in a designated record set for as long as the PHI is maintained in the designated record set. You should make your request to amend PHI to the Privacy Officer at their address listed on the first page of this Notice. We have the right to deny your request, but we will tell you why in writing within 60 days.

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

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

Ask us to limit what we use or share

• You May Request Restrictions on PHI Uses and Disclosures
• You may request the Plan to restrict the uses and disclosures of your PHI:
  • To carry out treatment, payment, or health care operations; or
  • To family members, relatives, friends, or other persons identified by you who are involved in your care.

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

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

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

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

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

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. Your Personal Representative will generally be required to produce evidence (proof) of the authority to act on your behalf before the Personal Representative will be given access to your PHI or be allowed to take any action for you.

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

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

In order for your legal Spouse to be your Personal Representative, you must complete a form, “Authorization for the Use and/or Disclosure of Protected Health Information ” and submit that form to the division. The form is available here .

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

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

Your Right to File a Complaint

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

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling (877) 696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints .

Your Choices

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

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

• Share information with your family, close friends, or others involved in payment for your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

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

• Marketing purposes
• Sale of your information

Definitions and Examples of Treatment, Payment, and Health Care Operations
Help manage the health care treatment you receive	Treatment is the provision, coordination, or management of health care and related services. It also includes but is not limited to coordination of benefits with a third party and consultations and referrals between one or more of your health care providers. For example: The Plan discloses to a treating specialist the name of your treating primary care physician so the two can confer regarding your treatment plan.
Pay for your health services	Payment includes but is not limited to making payment for the provision of health care, determination of eligibility, claims management, and utilization review activities such as the assessment of medical necessity and appropriateness of care. For example: The Plan tells your doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.
Administer your plan	Administering your plan includes but is not limited to quality assessment and improvement, patient safety activities, business planning and development, reviewing competence or qualifications of health care professionals, underwriting, enrollment, premium rating, and other insurance activities relating to creating or renewing insurance contracts. It also includes disease management, case management, conducting or arranging for medical review, legal services, and auditing functions including fraud and abuse compliance programs and general administrative activities. For example: The Plan uses information about your medical claims to refer you to a health care management program, to project future benefit costs, or to audit the accuracy of its claims processing functions.

The Plan’s Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Help manage the health care treatment you receive

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

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Pay for your health services

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

Administer your plan

We can use and disclose your information to run our organization and contact you when necessary. We may disclose your health information to your health plan sponsor for plan administration.

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

How else can we use or share your health information?

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

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

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

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

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

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

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

The Plan’s Duties

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

Notice Distribution

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

Notice Revisions

If a privacy practice of this Plan is changed affecting this Notice, a revised version of this Notice will be provided to you and all participants covered by the Plan at the time of the change. Any revised version of the Notice will be distributed within 60 days of the effective date of a material change to the uses and disclosures of PHI, your individual rights, the duties of the Plan or other privacy practices stated in this Notice.

Because our health plan posts its Notice on its website, we will prominently post the revised Notice on that website by the effective date of the material change to the Notice. We will also provide the revised notice, or information about the material change and how to obtain the revised Notice, in our next annual mailing to individuals covered by the Plan.

Breach Notification

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

Under federal law, group health plans like the AlaskaCare Employee Health Plan, generally may not restrict benefits for any hospital stay in connection with childbirth for the mother or the newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, the Plan may pay for a shorter stay if the attending physician (e.g., physician or health care practitioner), after consultation, discharges the mother or newborn earlier.

Also, under federal law, plans may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, the AlaskaCare Employee Health Plan may not, under federal law, require that a physician or other health care practitioner obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities or to reduce your out-of-pocket costs, you may be required to obtain pre-certification. For information on pre-certification for a length of stay longer than 48 hours for vaginal birth or 96 hours for cesarean section, contact the Aetna concierge at (855) 784-8646 to pre-certify the extended stay. You may also contact the Aetna concierge if you have questions about this notice.

Please review the AlaskaCare Employee Health Plan document for additional information.

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

Loss of Other Coverage Event

If you decline enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing towards the other coverage).

Marriage, Birth, Adoption Event

If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Medicaid/CHIP Event

You and your eligible dependents may also enroll in this plan if you (or your dependents):

• Have coverage through Medicaid or a State Children’s Health Insurance Program (CHIP) and you (or your dependents) lose eligibility for that coverage. However, you must request enrollment within 60 days after the Medicaid or CHIP coverage ends.
• Become eligible for a premium assistance program through Medicaid or CHIP. However, you must request enrollment within 60 days after you (or your dependents) are determined to be eligible for such assistance.

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

The health benefits that are available to you from the State of Alaska AlaskaCare Employee Health Plan represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury. In accordance with law, our employee plan provides you with Summary of Benefits and Coverage (SBC) documents to help you understand and compare medical plan benefits. Each SBC document summarizes and compares essential information including what is covered, what isn’t, what you need to pay for diverse benefits, and where to get answers to questions. The SBC documents are updated when there is a change to the benefits information.

To get a free copy of the most current SBC documents for our State of Alaska medical plan options and the uniform glossary that defines many terms in the SBC, go to AlaskaCare.gov, or for a paper copy, contact the Division of Retirement and Benefits toll-free at (800) 821-2251 or (907) 465-4460 in Juneau.

When you get emergency care or are treated by an out-of-network provider at a network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

"Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is likely more than network costs for the same service and might not count toward your annual out-of-pocket limit.

"Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at a network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

1. Emergency Care: If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
2. Certain services at a network hospital or ambulatory surgical center: When you get services from a network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in the network.

When balance billing isn’t allowed, you also have the following protections:

1. You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). The medical plan will pay out-of-network providers and facilities directly.
2. The plan generally must:
   • Cover emergency services without requiring you to get approval for services in advance (prior authorization or precertification).
   • Cover emergency services by out-of-network providers.
   • Base what you owe the provider or facility (cost-sharing) on what it would pay a network provider or facility and show that amount in your explanation of benefits.
   • Count any amount your pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed and would like to submit a complaint regarding potential violations of your balance billing protections, you may contact the federal Department of Health and Human Services:

• Phone number for information and complaints: (800) 985-3059
• Website: cms.gov/nosurprises/consumers

Note, consumer functionality for complaints inquiry will be operational January 2022.

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

If a dependent does not yet have a social security number, you can go to this website to complete a form to request an SSN: ssa.gov/forms/ss-5.pdf . Applying for a social security number is FREE.

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

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

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

• All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses; and
• Treatment of physical complications of the mastectomy, including lymphedema.

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

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

This Notice is required by law.

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

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

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

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

Effective Date

The effective date of this Notice is October 1, 2021, and this notice replaces notices previously distributed to you.

Privacy Officer

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

Your Protected Health Information

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

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

Your Rights to privacy with respect to your PHI

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

Get a copy of health and claims records

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

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

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

You Have the Right to Amend Your PHI

If you think your health or claims records are incorrect or incomplete, you or your Personal Representative have the right to request that the Plan amend your PHI or a record about you in a designated record set for as long as the PHI is maintained in the designated record set. You should make your request to amend PHI to the Privacy Officer at their address listed on the first page of this Notice. We have the right to deny your request, but we will tell you why in writing within 60 days.

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

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

Ask us to limit what we use or share

• You May Request Restrictions on PHI Uses and Disclosures
• You may request the Plan to restrict the uses and disclosures of your PHI:
  • To carry out treatment, payment, or health care operations; or
  • To family members, relatives, friends, or other persons identified by you who are involved in your care.

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

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

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

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

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

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. Your Personal Representative will generally be required to produce evidence (proof) of the authority to act on your behalf before the Personal Representative will be given access to your PHI or be allowed to take any action for you.

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

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

In order for your legal Spouse to be your Personal Representative, you must complete a form, “Authorization for the Use and/or Disclosure of Protected Health Information ” and submit that form to the division. The form is available here .

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

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

Your Right to File a Complaint

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

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling (877) 696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints .

Your Choices

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

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

• Share information with your family, close friends, or others involved in payment for your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

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

• Marketing purposes
• Sale of your information

Definitions and Examples of Treatment, Payment, and Health Care Operations
Help manage the health care treatment you receive	Treatment is the provision, coordination, or management of health care and related services. It also includes but is not limited to coordination of benefits with a third party and consultations and referrals between one or more of your health care providers. For example: The Plan discloses to a treating specialist the name of your treating primary care physician so the two can confer regarding your treatment plan.
Pay for your health services	Payment includes but is not limited to making payment for the provision of health care, determination of eligibility, claims management, and utilization review activities such as the assessment of medical necessity and appropriateness of care. For example: The Plan tells your doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.
Administer your plan	Administering your plan includes but is not limited to quality assessment and improvement, patient safety activities, business planning and development, reviewing competence or qualifications of health care professionals, underwriting, enrollment, premium rating, and other insurance activities relating to creating or renewing insurance contracts. It also includes disease management, case management, conducting or arranging for medical review, legal services, and auditing functions including fraud and abuse compliance programs and general administrative activities. For example: The Plan uses information about your medical claims to refer you to a health care management program, to project future benefit costs, or to audit the accuracy of its claims processing functions.

The Plan’s Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Help manage the health care treatment you receive

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

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

Pay for your health services

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

Administer your plan

We can use and disclose your information to run our organization and contact you when necessary. We may disclose your health information to your health plan sponsor for plan administration.

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

How else can we use or share your health information?

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

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

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

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

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

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

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

The Plan’s Duties

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

Notice Distribution

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

Notice Revisions

If a privacy practice of this Plan is changed affecting this Notice, a revised version of this Notice will be provided to you and all participants covered by the Plan at the time of the change. Any revised version of the Notice will be distributed within 60 days of the effective date of a material change to the uses and disclosures of PHI, your individual rights, the duties of the Plan or other privacy practices stated in this Notice.

Because our health plan posts its Notice on its website, we will prominently post the revised Notice on that website by the effective date of the material change to the Notice. We will also provide the revised notice, or information about the material change and how to obtain the revised Notice, in our next annual mailing to individuals covered by the Plan.

Breach Notification

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