Needs Review Not Apprvd
Fall 2021, Issue 37
Important AlaskaCare Benefit Program Notices
Updated October 2021
This newsletter contains important AlaskaCare benefit program notices of interest to you and your family. Please share this information with your family members. Some of the notices in this newsletter are required by law and other notices contain helpful information. These notices are updated from time to time and some of the federal notices are updated each year. Be sure you are reviewing the most updated version of these important notices.
Mental Health Parity and Addiction Equity Act
Notice to Enrollees in the AlaskaCare Employee Health Plan
Group health plans sponsored by State and local governmental employers must generally comply with Federal law requirements in title XXVII of the Public Health Service Act. However, these employers are permitted to elect to exempt a plan from the requirements listed below for any part of the plan that is “self-funded” by the employer, rather than provided through a health insurance policy. The Alaska Division of Retirement and Benefits (DRB) has elected to exempt the AlaskaCare Employee Health Plan (Plan) from the following requirement:
- Protections against having benefits for mental health and substance use disorders be subject to more restrictions than apply to medical and surgical benefits covered by the plan.
The exemption from these Federal requirements will be in effect for the 2022 plan year beginning January 1, 2022 and ending December 31, 2022. The exemption election may be renewed for subsequent plan years.
Although DRB has elected to exempt the Plan from federal parity protections for mental health and substance use disorders benefits, this does not necessarily mean that the Plan fails to provide these benefits in compliance with the federal protections. It means that the Plan is not legally required to comply with the federal protections and will not be subject to penalties or other legal consequences for failing to comply with the federal protections.
COBRA Coverage Reminder
In compliance with a federal law referred to as COBRA Continuation Coverage, this plan offers AlaskaCare members and their covered dependents (known as qualified beneficiaries) the opportunity to elect temporary continuation of their group health coverage when that coverage would otherwise end because of certain events (called qualifying events).
Qualified beneficiaries are entitled to elect COBRA when certain events occur, and, because of the event, coverage of that qualified beneficiary ends (together, the event and the loss of coverage are called a qualifying event). Qualified beneficiaries who elect COBRA Continuation Coverage must pay for it at their own expense. Current defined benefit retirees COBRA rates are available at Alaska.gov/AlaskaCare/retiree/information/cobraPremiums.html and current active COBRA rates are available on the Employee Health Coverage Continuation page.
Qualifying events may include termination of employment, reduction in hours of work making the employee ineligible for coverage, death of the employee, divorce/legal separation, or a child ceasing to be an eligible dependent child under the terms of the plan, if a loss of coverage results.
In addition to considering COBRA to continue coverage, there may be other coverage options for you and your family. You may want to look for coverage through the Health Care Marketplace at healthcare.gov. In the Marketplace, you could be eligible for a tax credit that lowers your monthly premiums for Marketplace coverage, and you can see what your premium, deductibles, and out-of-pocket costs will be before you decide to enroll. Being eligible for COBRA does not limit your eligibility for Marketplace coverage or for the tax credit. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan) if you request enrollment within 30 days, even if the plan generally does not accept late enrollees. The maximum period of COBRA coverage is usually either 18 months or 36 months, depending on which qualifying event occurred.
To have the chance to elect COBRA coverage after a divorce/legal separation, a child ceasing to be a dependent under the plan, or a determination by the Social Security Administration that a qualified beneficiary is disabled at any time during the first 60 days of COBRA coverage, you and/or a family member must inform the plan in writing of that event no later than 60 days after that event occurs.
Notices must be sent via first class mail to:
- Division of Retirement and Benefits
P.O. Box 110203
Juneau, AK 99811-0203
We Value Your Feedback!
As an AlaskaCare Retiree member, your input is valued and important. Below, please see a list of ways to contact us with your feedback. Also, a full list of AlaskaCare health plan and partner contact information can be found on our website.
- Toll Free: (800) 821-2251
- In Juneau: (907) 465-4460
- TDD: (907) 465-2805
- Fax: (907) 465-3086
- Email: email@example.com
Send us a letter:
State of Alaska
Division of Retirement and Benefits
P.O. Box 110203
Juneau, AK 99811-0203
Come visit us:
State Office Building
333 Willoughby Avenue
Juneau, AK 99801
Important Notice for AlaskaCare Employees About Prescription Drug Coverage and Medicare
This notice has information regarding your AlaskaCare prescription drug coverage and the options available to you. This information can help you decide if joining a Medicare drug plan is right for you. If you are considering joining, compare your current AlaskaCare coverage, including which drugs are covered and at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. If you would like assistance with choosing the right prescription drug coverage, please see the end of this notice.
Medicare prescription drug coverage is available to Medicare eligible people through Medicare Prescription Drugs Plans (PDPs) and Medicare Advantage Plans (like an HMO or PPO) that offer prescription drug coverage. All Medicare drug plans provide a standard level of coverage set by Medicare. Some other plans may also offer more coverage for a higher monthly premium.
The State of Alaska has determined that the prescription drug coverage is “creditable” under the AlaskaCare Employee Health Plan. “Creditable” means that the value of the Plan’s prescription drug benefit is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays. Because the plan options noted above are Creditable Coverage, you can elect or keep prescription drug coverage under the plan and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare prescription drug plan.
When Can You Join a Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare or during Medicare’s annual election period (from October 15 to December 7). You may also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan in some special circumstances.
What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan?
You can select or keep your current prescription drug coverage with the AlaskaCare employee plan, and you do not have to enroll in a Medicare prescription drug plan. If you do decide to join a Medicare drug plan, your AlaskaCare coverage will be affected as follows: As a participant in the State’s employee health plan, if you purchase Medicare prescription drug coverage, Medicare will pay secondary, and the State employee health plan will pay primary.
When will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?
If you lose or drop your AlaskaCare coverage 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 Medicare prescription drug coverage or a creditable prescription drug plan. For example, if you go 19 months without creditable coverage, your premium will always 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, if you go 63 days or longer without prescription drug coverage you may have to wait until the following October to enroll for Medicare prescription drug coverage.
For more information about this notice contact the Alaska Medicare Information Office at (800) 478-6065 or in Anchorage at (907) 269-3680. For more information about your AlaskaCare Prescription Drug Coverage, contact the Aetna concierge at (855) 784-8646.
NOTE: This notice will be sent to you each year, before the next available period in which you can join a Medicare drug plan, and if there are any changes to your AlaskaCare prescription drug coverage. You also may request a copy of this notice at any time.
For more detailed information about Medicare plans that offer prescription drug coverage, please see the “Medicare & You” handbook. Every year Medicare will send a copy of the handbook through the mail. Medicare may also contact you directly regarding their drug plans. For more information about Medicare prescription drug coverage please see the following:
- Visit medicare.gov.
- 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 (800) MEDICARE. TTY users should call (877) 486-2048.
If you have limited income and resources, assistance in paying for Medicare prescription drug coverage is available. For information about payment assistance, please visit Social Security on the web at socialsecurity.gov, or call at (800) 772-1213. TTY users should call (800) 325-0778.
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice in order to show whether you have maintained creditable coverage and, therefore, whether you are required to pay a higher premium (a penalty).
Notice of Special Enrollment Rights
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.
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.
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 list of states below is current as of July 31, 2021. Contact your State for more information on eligibility.
To see if any other states have added a premium assistance program since July 31, 2021, or for more information on special enrollment rights, contact either:
- U.S. Department of Labor
Employee Benefits Security Administration
- U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services
1-877-267-2323, Menu Option 4, Ext. 61565
|ALABAMA - Medicaid||NEVADA - Medicaid|
Phone: (855) 692-5447
Phone: (800) 257-8563
|ALASKA - Medicaid||NEW JERSEY - Medicaid and CHIP|
|The AK Health Insurance Premium Payment Program Website:
Phone: (866) 251-4861
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|
Phone: (800) 541-2831
|CALIFORNIA - Medicaid||NORTH CAROLINA - Medicaid|
|Health Insurance Premium Payment (HIPP) Program
Phone: (916) 445-8322
|Website: medicaid.ncdhhs.gov Phone: (919) 855-4100|
|COLORADO - Medicaid and CHP+||NORTH DAKOTA - Medicaid|
|Health First Colorado & Child Health Plan Plus
Phone: (800) 221-3943 | State Relay 711
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
Phone: (844) 854-4825
|FLORIDA - Medicaid||OKLAHOMA - Medicaid and CHIP|
Phone: (877) 357-3268
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
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|
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
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)
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|
Phone: (800) 862-4840
Phone: (800) 250-8427
|MINNESOTA - Medicaid||VIRGINIA - Medicaid and CHIP|
|Phone: (800) 657-3739||Websites: coverva.org/en/famis-select
Medicaid Phone: (800) 432-5924
CHIP Phone: (800) 432-5924
|MISSOURI - Medicaid||WASHINGTON - Medicaid|
Phone: (573) 751-2005
Phone: (800) 562-3022
|MONTANA - Medicaid||WEST VIRGINIA - Medicaid|
Phone: (800) 694-3084
Toll-free phone: (855) 699-8447
|NEW HAPMSHIRE - Medicaid||WISCONSIN - Medicaid and CHIP|
Phone: (603) 271-5218 | Toll-free: (800) 852-3345, ext. 5218
Phone: (800) 362-3002
|NEBRASKA - Medicaid||WYOMING - Medicaid|
Phone: (855) 632-7633
Phone-Lincoln: (402) 473-7000
Phone-Omaha: (402) 595-1178
Phone: (800) 251-1269
Notice of HIPAA Privacy Practices
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.”
The effective date of this Notice is October 1, 2021, and this notice replaces notices previously distributed to you.
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
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).
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 on the DRB Webpage. 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.
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 on the DRB Webpage.
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.
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
|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.