Benefits Summary Booklet€¦ · Bellevue, WA 98004 1‐866‐576‐0201 Deferred Comp Program...

This is a brief summary of benefits prepared by The Unity Group, the employee benefits insurance broker for Sedro‐

Woolley School District. This is not a certificate of coverage. For full coverage provisions, including a description of

waiting periods, limitations and exclusions, refer to the benefits plan documents and contracts. If there is a conflict

between this summary and the official plan documents, the actual plan document will govern in all cases.

Benefits Summary Booklet

IMPORTANT!If you have Medicare or will become eligible for Medicare in the next 12 months, Federal law gives you more choices about your prescription drug coverage. Please see page 19 for more details.

2011‐2012 School Year

Table of Contents Welcome 1 Key Contacts 1 Eligibility 2 Mandatory Benefits 3 Washington Dental Service / WEA Select Plan C 3 Vision Services Plan / WEA Select PlanD 3 Optional Medical Benefits 4 Group Health 5 Premera Blue Cross/WEA Select 7 Benefit Allocation 9 Monthly Medical Premiums 9 Monthly Payroll Deductions 9 Other Voluntary Benefits 10 Short Term Disability 10 Section 125 – Flexible Spending Account 10 Tax Sheltered Annuities 10 Deferred Compensation Plan 11 Credit Unions 11 Other Important Information 11 Children’s Health Insurance Program (CHIP) 11 Apple Health for Kids 11 Women’s Health and Cancer Act 12 Newborns’ and Mothers’ Health Protection Act 12 Michelle’s Law 12 Out‐of‐Area Benefits 12 COBRA 12 HIPAA 17 Special Enrollment Rights 18 Medicare Part D 19

Welcome!

This Enrollment Guide is also available online at www.theunitygroup.com, click on the My Benefits button. Your user login is laconnersd and your password is also laconnersd.

Key Contacts Group Health Cooperative www.ghc.org PO Box 34585 Seattle, WA 98124 1‐888‐901‐4636

Department of Retirement Systems WWW.DRS.WA.GOV PO BOX 48380 OLYMPIA, WA 98504 1‐800‐547‐6657

Premera Blue Cross www.premera.com/wea PO Box 91059 Seattle, WA 98111 1‐800‐932‐9221

Washington Dental Service / WEA www.deltadental.com PO Box 75688 Seattle, WA 98175‐0688 1‐800‐554‐1907

School Employees Credit Union of Washington www.secuwa.org 325 Eastlake Avenue E Seattle, WA 98109‐5407 1‐888‐628‐4010

American Fidelity Assurance Co. www.afadvantage.com kelly.daniels@af‐group.com 3055 112th Ave. NE, Suite 225 Bellevue, WA 98004 1‐866‐576‐0201

Deferred Comp Program [email protected] PO Box 40931 Olympia, WA 98504‐0931 1‐888‐327‐5596

My Benefits This Enrollment Guide is also available online at www.theunitygroup.com, click on the My Benefits button. Your user login is laconnersd and your password is also laconnersd.

Working Solutions Program (Employee Assistance) www.liveandworkwell.com Aon Consulting 1200 Sixth Avenue, Suite 2000 Seattle, WA 98101‐1128 1‐800‐358‐8515

Washington Education Association www.washingtonea.org PO Box 9100 Federal Way, WA 98001‐9687

The Unity Group Home and Auto Insurance www.theunitygroup.com 110 Unity Street Bellingham, WA 98225 1‐800‐339‐9270

For Questions About Benefits Contact:David Cram 360.466.3171 Director of Business & Operations

La Conner School DistrictBenefits Summary Booklet Page 1

Preparead by The Unity Group

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Eligibility Employee Eligibility New benefits‐eligible employees have 30 days to enroll in all the benefit options. Employees not enrolling within 30 days of their eligibility date will next be available to enroll during Open Enrollment. For some benefits, there may be eligibility requirements and a medical review that must be met to participate outside the 30 days of eligibility. Participation would not be guaranteed. Benefits changes, including adding dependents or changing insurance plans, can only be done during Open Enrollment, unless there is a qualifying event. Current employees need not re‐enroll during Open Enrollment unless a change in enrollment is desired. Dependent Eligibility

** Important Notice** Health Care Reform law requires dependent coverage be available until a child reaches the age of 26. Both married and unmarried children qualify

for this coverage Eligible dependents include:

1. The subscriber’s lawful spouse. If your spouse has coverage with an employer and loses that coverage, they may be eligible for COBRA through their employer. In lieu of COBRA coverage through their employer, they may be eligible to be added to the District employee’s coverage, without waiting until the next open enrollment. They must show proof of lost coverage, through no fault of their own (Certificate of Creditable Coverage).

2. The domestic partner of the subscriber. If all requirements are met, as stated in the signed “Affidavit of Qualifying Domestic Partnership,” all plan provisions stated as applicable to a spouse will also be applicable to a domestic partner.

3. A natural child, adopted child or child legally placed for adoption (including a child for whom the employee has assumed a total or partial legal obligation for support in anticipation of adoption), stepchild, or legally designated minor ward. This child must be under the age of 26. The child cannot have other coverage available due to his/her employment. In addition, a child of the employee will be eligible for coverage under this plan when required by a court order. Children who are incapacitated due to a developmental disability or physical handicap and chiefly dependent upon the subscriber for support and maintenance are also eligible for benefits, provided the dependent child was covered on the day before the 26th birthday and the incapacity occurred prior to the 26th birthday. Benefits will be provided for the duration of the incapacity unless coverage terminates. Proof of the incapacity and dependency will be required within 31 days after the child’s 26th birthday and not more frequently than one time per year after the child’s 28th birthday.

If you are the Legal Guardian of an unmarried child or children, these children may be enrolled in this Plan as covered Dependents. Any child of a Plan Participant who is an alternate recipient under a Qualified Medical Child Support Order (QMCSO) shall be considered as having a right to Dependent coverage under this Plan. A participant of this Plan may obtain, without charge, a copy of the procedures governing QMCSO determinations from the Department of Labor Website. www.dol.gov/ebsa/publications/qmcso.html.



Mandatory Benefits Per your bargaining agreement, dental and vision shall be the first premiums deducted from the funds provided to you by the District to pay for medical benefits. Important Notice Regarding Washington Dental Service (WDS) Currently, the Plan Year (when rates and benefit changes become effective) is October 1 – September 30. However, the Benefit Year (when the annual benefit maximum renews) is September 1 – August 31. The Benefit Year will be adjusted to coincide with the Plan Year as follows:

• The current benefit year (2010‐11) will be extended one month and all enrollees will receive an additional $170 for the month of September. Enrollees will then receive their full benefit effective October 1, 2011.

• This “extra” benefit will be available in addition to any remaining balance of an enrollee’s 2010‐11 benefit maximum. • Going forward, the benefit maximum will renew on October 1st of every year.

Washington Dental Service (WDS) ∙ Plan C Vision ‐ Premera Blue Cross ∙ Plan D

Any Licensed Dentist Benefits for: Any Licensed Provider Benefit Year Deductible $0 Benefit Year Maximum (Per Person) $1,750

*$2,000 when a Delta Dental PPO Provider is used

Materials $15 copay, then paid as shown below

Examination Once per calendar year: Class I Diagnostic and Preventive Services Exams, x‐rays, cleanings

100%

Paid in full after $5 copay

Lenses (pair) Once per calendar year: Single Vision 100% of allowable charge

Class II Routine Care Fillings, extractions, endodontics, oral surgery

80% Bifocal 100% of allowable charge

Trifocal 100% of allowable charge Major Services Dentures, bridges, partials

50% Lenticular 100% of allowable charge

Pre‐determination Limit: Pre‐determination is recommended, but not required for dental services.

Lens Tinting, Coating, or Oversize Lenses

$15

Contact Lenses once every two calendar years(in lieu of frames and eyeglass lenses)

$200

Medically necessary contacts lenses once every calendar year in lieu of eyeglass lenses

100% of allowable chart

Frames Once per 2 calendar years:

Late Enrollment Penalty: If an employee or dependent does not enroll onto the dental plan within 31 days of initially becoming eligible, they cannot enroll until the next open enrollment period. Benefit Year: Runs from 10/01/2011 through 09/30/2012

$65 Composite Rate* ‐ $88.95 monthly Monthly Composite Rate* $23.30

*Composite means one fee regardless of number of family members covered.



Optional Benefits Medical Plans Enrolling in a medical plan can only be done during your initial eligibility or during Open enrollment. If you do not wish to make any changes, your current plan selection continues automatically. The district offers you seven separate medical plans. These plans offer you a choice between managed care and preferred provider coverage. It is important to review the programs carefully. This booklet may not include important coverage information including definitions, conditions of coverage, exclusions, pre‐existing conditions, and other limitations on the medical plans. Please refer to the specific plan book for information applicable to coverage. Plan books are available on the My Benefits website (see Key Contacts section of this booklet for login information), from your HR/Benefits Department or through the carrier. Group Health Cooperative (GHC) Group Health Cooperative was opened in 1947 by a community coalition dedicated to making quality health care available and affordable. GHC is one of the nations original Health Maintenance Organizations (HMO).

HMO Plan This is a staff model cooperative (consumer board governed) with over 1,100 primary care physicians delivering care to approximately 600,000 members in the Pacific Northwest. Preventive care is covered and encouraged. Services must be provided or authorized by a GHC staff to be covered. Members can self‐refer to some Group Health staff model specialists. More than 70 percent of members receive care in Group Health owned medical facilities. In Skagit, Whatcom and Island Counties, this care is received with local physicians that have contracted with GHC to provide managed care services. Local hospitals and physician clinics are a part of the GHC managed health care network. You will need to choose a Primary Care Physician PCP. Your PCP will need to coordinate referrals should you need to see a specialist or other provider.

Premera Blue Cross ∙ WEA Select Seven plans with varying cost sharing, premiums and networks are offered, allowing participants to choose the plans best suited for their needs. These plans are all Preferred Provider Organization (PPO) plans. Premera, like Regence, maintains special contractual relationships with the providers who appear on the list of preferred providers. If a provider is not on the list, coverage will generally be reimbursed at a lower rate. Premera’s PPO plan also includes participation in a National BlueCard program. This allows access to Blue Cross and BlueShield PPO networks nationwide. All WEA Select plans include a $20,000 decreasing Term Life and AD&D plan.



Benefit Summary

Laconner School District

Effective Date 10/1/2011 Health Plan Group Health Ref QR-37581

This is a brief summary of benefits. THIS IS NOT A CONTRACT OR CERTIFICATE OF COVERAGE. All benefit descriptions, including alternative care,are for medically necessary services. The Member will be charged the lesser of the cost share for the covered service or the actual charge for that service.For full coverage provisions, including limitations, please refer to your certificate of coverage.

In accordance with the Patient Protection and Affordable Care Act of 2010,

The lifetime maximum on the dollar value of covered essential health benefits no longer applies. Members whose coverage ended by reason ofreaching a lifetime limit under this plan are eligible to enroll in this plan, andDependent children who are under the age of twenty-six (26) are eligible to enroll in this plan.

Benefits Inside Network

Plan deductible No annual deductible

Individual deductiblecarryover

Not applicable

Plan coinsurance No plan coinsurance

Out-of-pocket limit

Individual out-of-pocket limit: $2,000Family out-of-pocket limit: $4,000

Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit:

Inpatient services, outpatient services, emergency services at a GHC or non-GHC facility, ambulance services.

Pre-existing condition(PEC) waiting period

No PEC

Lifetime maximum Unlimited

Outpatient services(Office visits)

$15 copay

Hospital servicesInpatient services: Covered in fullOutpatient surgery: $15 copay

Prescription drugs(some injectable drugs maybe covered under Outpatientservices)

Formulary generic and/or brand$15 copay per 30 day supply

Prescription mail order 2 x prescription cost share per 90 day supply

AcupunctureSelf-referred up to 8 visits per medical diagnosis per calendar year; additional visits when approved by the plan$15 copay

Ambulance services Plan pays 80%, you pay 20%

Chemical dependencyInpatient: Covered in fullOutpatient: $15 copay

Devices, equipment andsupplies

Durable medicalequipmentOrthopedicappliancesPost-mastectomybras limited to two (2)every six (6) months

Ostomy suppliesProsthetic devices

Covered at 80%

Covered at 80%

Diabetic suppliesInsulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testingreagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugsare covered and have benefit limits, diabetic supplies are not subject to these limits.



Diagnostic lab and X-rayservices

Inpatient: Covered under Hospital servicesOutpatient: Covered in full

High end radiology imaging services such as CT, MR and PET must be determined Medically Necessary and requirepreauthorization except when associated with Emergency care or inpatient services.

Emergency services(copay waived if admitted)

$75 copay at a designated facility$75 copay at a non designated facility

Hearing exams (routine) $15 copay

Hearing hardware Not covered

Home health services Covered in full. No visit limit.

Hospice services Covered in full

Infertility services Not covered

Manipulative therapySelf-referred up to 20 visits per calendar year$15 copay

Massage services See Rehabilitation services

Maternity servicesInpatient: Covered in fullOutpatient: $15 copay

Mental HealthInpatient: Covered in fullOutpatient: $15 copay

NaturopathySelf-referred up to 3 visits per medical diagnosis per calendar year; additional visits when approved by plan$15 copay

Newborn ServicesAny applicable coinsurance applies to the newborn while both mother and baby are confined. Otherwise, all applicableinpatient cost shares apply. Office visits: See Outpatient Services; Routine well care: See Preventive care.

Obesity-related surgery(bariatric)

Not covered

Organ transplantsDonor search & harvestapplies to lifetime max

Unlimited, no waiting period

Inpatient: Covered in fullOutpatient: $15 copay

Preventive careWell-care physicals,immunizations, Pap smearexams, mammograms

Covered in full

Rehabilitation services(Occupational, speech,physical including services forneurodevelopmentallydisabled children age six andunder)Rehabilitation visits are a totalof combined therapy visits percalendar year

Inpatient: 60 days per calendar yearCovered in fullOutpatient:60 visits per calendar year$15 copay

Skilled nursing facility Covered in full up to 60 days per calendar year

Sterilization (vasectomy,tubal ligation)


Temporomandibular Joint(TMJ) services

$1,000 per calendar year; $5,000 lifetime max


Tobacco cessationcounseling

Free & Clear Program - covered in full

Routine vision care(1 visit every 12 months)

$15 copay

Optical hardwareLenses, including contactlenses and frames

Not covered

Coverage provided by Group Health Cooperative QR-37581



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Benefits that have changed are highlighted in gray Ded + Coin = Deductible + Coinsurance Applies to all plans as shownIN = In-network OUT = Out-of-network PCY = Per Calendar Year OT = Occupational therapy PT = Physical therapy

EasyChoice A EasyChoice B EasyChoice CProvider Network Heritage Heritage Foundation

Copayments, Deductible & Coinsurance IN OUT IN OUT IN OUT

CopaymentsOffice Visit $15* 50% $30* 50% $35* 50%Inpatient Copay Individual None

Family N/AOutpatient Surgery Copay None

ER Copay (waived if admitted) $100 $100 $150 $150 $200 $200

DeductibleDeductible PCY Individual $1,000 $2,000 $750 $1,500 $0 $250

Family $3,000 $6,000 $2,250 $4,500 $0 $750

CoinsuranceCoinsurance 20% 50% 25% 50% 35%* 50%Out-of-Pocket Maximum PCY** Individual $5,000 None $4,000 None $7,500 None

Family $15,000 None $12,000 None $22,500 None

Covered Services IN OUT IN OUT IN OUT

Office Visits – Professional CareMedical and Naturopathic Office Visits unlimited $15* 50% $30* 50% $35* 50%Spinal and Other Manipulations 12 visits PCY (chiropractic)

$15* 50% $30* 50% $35* 50%

Acupuncture 12 visits PCY $15* 50% $30* 50% $35* 50%

Preventive Care unlimitedExams/Immunizations IN: $0* OUT: Not coveredPreventive Screenings (includes mammography and colon health screenings)

IN: $0* OUT: 50%

Diagnostic ServicesDiagnostic Imaging/Laboratory Paid in full to $1,000 then Ded + Coin Ded + Coin

Hospital/Facility CareOutpatient Ded + CoinInpatient Ded + CoinMaternity – Prenatal/Postnatal Care Ded + CoinMaternity – Delivery Ded + Coin

Emergency CareProfessional / Facility ER Copay + Ded + CoinAmbulance (air and ground) Ded + Coin

Mental Health Outpatient unlimited visits $15* 50% $30* 50% $35* 50%

Mental Health Inpatient unlimited days Ded + Coin

Rehabilitation Outpatient A:30 visits PCY, B&C: 45 visits PCY (PT, Massage, Speech, OT)

$15* 50% $30* 50% $35* 50%

Rehabilitation Inpatient A: 30 days PCY, B&C: 45 days PCY Ded + Coin

Prescription Drugs (participating pharmacies only) Generic / Preferred Brand Name / Non-preferred Brand Name

Rx Deductible (waived for generics) per person PCY $500 $250 $500Rx Out-of-Pocket Maximum per person PCY; includes

Rx deductible, coinsurance and/or copay$5,000

Retail Cost Share 30 day supply $0 / 30% / 30% $0 / $30 / $45Mail Order Cost Share 90 day supply $0 / 25% / 25% $0 / $75 / $112Specialty Drug Cost Share 30 day supply 30%

Unum (Life & AD&D insurance) † $12,500 Term Life and AD&D for employee only

EasyChoice Plan

020684 (07-2011)Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

* Not subject to the calendar year deductible** Out-of-pocket maximums include coinsurance and deductible. Covered in-network services paid at 100% of allowable charges for remainder of the calendar year once out-of-pocket

maximum is met. No out-of-pocket maximum for out-of-network services. † Unum is an independent provider of life insurance services that does not provide Premera Blue Cross products or services. Unum is solely responsible for its products and services.

NOTE: This summary is intended to assist you in decision making. Details of covered benefits, limitations, and exclusions are provided in the WEA Select Health Plan benefit booklets. This summary of benefits is not a contract.

WEA Select Health Plans October 1, 2011



sherim

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Benefit Allocation The benefit allocation for employee benefits per FTE in 2011‐2012 is $768.00. The amount available to apply towards medical insurance is determined after mandatory benefits have been provided for as noted in the table below.

1.0 FTE $768.00 Less: Retiree Carve Out ($66.01)

Add: District Paid Portion of Retiree Subsidy $66.01 Less: Mandatory Benefits Washington Dental Plan ($88.95) WEA Select Vision Plan ($23.30)

Net Funds Available for Medical $655.75

2011 – 2012 Monthly Medical Premiums GHC HMO Employee $690.43 Employee + Spouse $1,337.02 Employee + Child(ren) $964.30 Employee + Family $1,610.89 WEA Select Premera Blue Cross

Plan 1 Plan 2 Plan 3 EasyChoice Plans Plan 5

Employee $806.15 $617.95 $552.80 $421.55 $723.15 Employee + Spouse $1,531.15 $1,166.15 $1,043.45 $793.85 $1,432.70 Employee + Child(ren) $1,113.10 $850.20 $760.75 $579.25 $1,016.75 Employee + Family $1,838.10 $1,398.40 $1,251.40 $951.55 $1,726.30

2011 – 2012 Monthly Payroll Deductions The amounts shown below are approximate monthly payroll deductions prior to pooling for a 1.0 FTE. Listed in the chart below are the 2011‐2012 monthly deductions for each plan. This is calculated by taking the total Benefit Allocation (as shown in the Benefit Allocation table), less mandatory benefits, less monthly medical premiums. The premium amount deducted from your paycheck may change after the September payroll and again after the October payroll. Deductions are determined from final pooling numbers that are calculated after the September enrollment is known and again after October enrollment is known. The pooling may cause a change in the amount of money applied toward your premium reductions and, as a result, may change your out‐of‐pocket amount. GHC HMO Employee $34.68 Employee + Spouse $681.27 Employee + Child(ren) $308.55 Employee + Family $955.14

WEA Select Premera Blue Cross

Plan 1 Plan 2 Plan 3 EasyChoice Plans Plan 5

Employee $150.40 $0.00 $0.00 $0.00 $67.40 Employee + Spouse $875.40 $510.40 $387.70 $138.10 $776.95 Employee + Child(ren) $457.35 $194.45 $105.00 $0.00 $361.00 Employee + Family $1,182.35 $742.65 $595.65 $295.80 $1,070.55



Other Voluntary Benefits

Short Term Disability (STD) – American Fidelity Assurance Company ∙ WEA Select Short Term disability is available to you. The premium will be an additional payroll deduction from your pay. You should contact your benefits specialist for a brochure and application if you are interested. The premium is based on your Annual Gross Salary, so premiums will vary. The brochure will provide you with the applicable premium. Section 125 Flexible Spending Account‐ American Fidelity Assurance Company Is Your Paycheck Saving You Money? The Section 125 Plan allows you to deduct needed benefits from gross earnings before taxes are computed. What that means is that current after‐tax expenses for insurance products and benefits can now be paid for with pre‐tax dollars. Plus, the Plan is available to you at no cost* and you’re already eligible, all you have to do is enroll. By implementing this plan, your employer is helping you reduce your taxes and increase your spendable income. This cost saving advantage of the plan is simple. Any benefit costs or insurance premiums you pay under the plan are paid on a pre‐tax basis. How Can this Plan Help You? The illustration shows the advantage of the Section 125 Plan in comparison to benefits outside of the Plan. The sample paycheck with the Section 125 Flexible Benefit Plan has $70 of more spendable income per month!

Without Section 125 With Section 125 Monthly Gross Salary $2,000 $2,000 Less Pre‐Tax Medical, Dental, Dependent Care N/A $ ‐250 TAXABLE SALARY $2,000 $1, 750 Less 20% Federal Income Tax ‐$ ‐400 ‐$ 350 Less 7.65 FICA and FUTA Tax ‐$ 153 ‐$ 133 Medical Deductions $ 250 N/A Monthly Take Home Pay $1,197 $1,267

Are you Saving Money On Dependent Day Care and Out‐of‐Pocket Medical Expenses? You can direct a part of your pay, on a pre‐tax basis, into Flexible Spending Accounts (FSA) that can be used to reimburse yourself for Dependent Day Care expenses and/or Unreimbursed Medical expenses. As you incur a qualified Dependent Day Care or Unreimbursed Medical expense, you submit the appropriate claim paperwork to American Fidelity for reimbursement. A Dependent Day Care FSA is sued to reimburse yourself for eligible dependent care expenses incurred and allow you to work or, if you are married, your spouse to work or look for work. You may allocate up to $5,000 pre‐tax per calendar year for reimbursement of dependent care services (2,500 if you are married and file a separate tax return). An Unreimbursed Medical Account (also known as Health FSA) may be used to reimburse yourself for eligible medical expense incurred for yourself, your spouse, or child(ren) through the end of the tax year in which the child turns 26 , and you eligible dependents. Examples of eligible expenses may include but are not limited to medical deductibles, coinsurance payments, prescriptions and other medical expenses not reimbursed by another source. Please Note: If you do not file sufficient claims for reimbursement, you will lose the unused amounts. This is often referred to as the “use‐or‐lose” rule. Therefore, the balance of the unused amounts must be forfeited to your Employer.

Tax Sheltered Annuities TSA’s provide a way to defer income for use when you retire. Federal Tax Law provides that an employee of a public school may agree with their employer to set aside a portion of salary in a 403(b) annuity contract/custodial account. The portion set aside into a TSA reduces the employee’s current year taxable income and provides a deferred‐tax benefit. The IRS regulates the amount you may set aside each year. Enrollment and changes can be made at any time during the year. The Benefits Department has a list of investment companies which have been authorized to provide services to employees. There must be a least five participants for any investment company to remain on the authorized list. The District does not represent, imply, or offer recommendations on any particular tax‐deferred account type nor the investment companies offering the contracts. Advice should be sought from your tax advisor or through other investment or TSA professionals. The list of investment companies and a handbook describing the TSA program are available from the HR/Benefits Department.



Deferred Compensation Plan In addition to investing in a TSA, employees can also participate in the Deferred Compensation Plan (DCP) under the Internal Revenue Code 457. It is a supplemental retirement plan that provides District employees control and flexibility over their individual investments while reducing federal taxes owed for the current year. The plan provides an option to employees to invest income from their monthly paycheck on a tax‐deferred basis. DCP has low management and administrative fees, no penalties on withdrawals, and portability. The Department of Retirement Systems (DRS) administers the plan. A brochure is available in the HR/Benefits Department or by contacting DRS at (800) 547‐6657 or through their website at www.drs.wa.gov . You would enroll by contacting DRS directly.

Credit Unions All employees of the District, including substitutes, are eligible to join the credit union. Employees may have their paycheck automatically deposited into the credit union. If you wish to enroll in the credit union, you can do so by contacting the HR/Benefits Department or you may contact the credit union directly. Contact information is listed in the Key Contacts section of this booklet. Other Important Information Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free Or Low‐Cost Health Coverage To Children And Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer‐sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1‐877‐KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer‐sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. Contact your State for further information on eligibility –

Washington – Medicaid Website: http://ihrsa/sites/DCS/COB/default.aspx

Phone: 1‐800‐562‐6136

To see if any more States have added a premium assistance program since February 16, 2010, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1‐866‐444‐EBSA (3272) 1‐877‐267‐2323, Ext. 61565 OMB Control Number 1210‐0137 (expires 09/30/2013)

Apple Health for Kids Medical, dental, vision and mental health coverage for kids 18 or younger. Includes coverage for speech, physical and occupational therapy. Monthly premiums are $0, $20 or $30 per child per month. WAHA offers same‐day application appointments or visit them online at http://hrsa.dshs.wa.gov/applehealth/am_i_eligible.shtml ‐ 1‐877‐543‐7669.



Breast Cancer Rights ....What you should know Women’s health issues have long been a top priority. We stress the importance of preventive care, like mammograms and pap smears, and when these screenings detect cancer, we cover treatment.* The Women’s Health & Cancer Rights Act of 1988 This law requires health plans to provide coverage for the breast reconstruction after a mastectomy has been performed; coverage for surgery and reconstruction on the other breast to produce symmetrical appearance; and coverage for prostheses and any physical complications during all stages of the mastectomy, including lymph edemas. These benefits may be subject to deductible and co‐payment provisions, if your plan includes such provisions. Additional details about this coverage are provided in your Evidence or Certificate of Coverage. You should keep this notice for your records. If you have questions For more information, you may contact the appropriate Customer Service Department for the health plan that you have chosen. Carrier phone numbers are provided in this guide. *Except for investigational or experimental treatments.

Newborns’ and Mothers’ Health Protection Act (NMHPA) Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean delivery. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). The group health plan does not need to provide the minimum period of coverage for maternity stay if the mother and health care provider agree to earlier discharge. A provider is not required to obtain authorization for a length of stay that is not in excess of 48 hours (or 96 hours). Michelle’s Law Michelle’s Law allows full‐time college students to take up to 12 months medical leave and applies to students who are covered under their parent’s health insurance plan. “Medical leave” can mean that the student is absent from school or reduces his/her course load to part‐time. The date the medical leave begins is determined by a student’s physician. H.R. 2851 signed into Federal law on October 9, 2009, the legislation was officially named “Michelle’s Law” and took effect immediately. Out‐of‐Area Benefits If you are living or traveling outside of Washington and need medical care, you may use a Blue Cross or BlueShield PPO provider to receive the same benefits as the preferred level of your plan. When you are outside of the service area and need medical care, call the BlueCard Access Line at (800) 810‐BLUE (2583) for information on the nearest PPO doctors and hospitals. The doctor or hospital will verify your membership and coverage information after you present your identification/membership card. The doctor or hospital will electronically route your claim to your BlueShield plan for processing. Because all PPO providers are paid by the plan directly, you are not required to pay for the care at time of service and then wait for reimbursement. You will only need to pay for out‐of‐pocket expenses, such as non‐covered services, deductible, co‐pays and co‐insurance. This applies only to those employees who have elected coverage through Premera. Consolidated Omnibus Reconciliation Act of 1985 (COBRA) Introduction The right to COBRA Continuation Coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (“COBRA”). COBRA Continuation Coverage can become available to you when you otherwise would lose your group health coverage. It also can become available to other members of your family who are covered under the Plan when they otherwise would lose their group health coverage. The entire cost (plus a reasonable administration fee) must be paid by the Covered Employee (or former Employee), Qualified Beneficiary, or any representative acting on behalf thereof. Coverage will end in certain instances, including, but not limited to, if you or your Dependents fail to make timely payment of premiums. You should check with your Employer to see if COBRA applies to you and your Dependents.



What is COBRA Continuation Coverage? “COBRA Continuation Coverage” is a continuation of Plan coverage when coverage otherwise would end because of a life event known as a “Qualifying Event.” Life insurance, accidental death and dismemberment benefits and weekly income or long‐term disability benefits (if a part of your Employer’s plan) are not considered for continuation under COBRA. What is a Qualifying Event? Specific Qualifying Events are listed below. After a Qualifying Event, COBRA Continuation Coverage must be offered to each person who is a “Qualified Beneficiary.” You, your Spouse, and your Dependent children could become Qualified Beneficiaries if coverage under the Plan is lost because of the Qualifying Event. A domestic partner is not a Qualified Beneficiary. If you are a Covered Employee (meaning that you are an Employee and are covered under the Plan), you will become a Qualified Beneficiary if you lose your coverage under the Plan due to one of the following Qualifying Events:

• Your hours of employment are reduced; or • Your employment ends for any reason other than your gross misconduct.

If you are the Spouse of a Covered Employee, you will become a Qualified Beneficiary if you lose your coverage under the Plan due to one of the following Qualifying Events:

• Your Spouse dies; • Your Spouse’s hours of employment are reduced; • Your Spouse’s employment ends for any reason other than his or her gross misconduct; • Your Spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); • You become divorced or legally separated from your Spouse; or In certain circumstances, you are no longer eligible for coverage under

the Plan.

Note: Medicare entitlement means that you are eligible for and enrolled in Medicare. Your Dependent children will become Qualified Beneficiaries if they lose coverage under the Plan due to one of the following Qualifying Events:

• The parent‐Covered Employee dies; • The parent‐Covered Employee’s hours of employment are reduced; • The parent‐Covered Employee’s employment ends for any reason other than his or her gross misconduct; • The parent‐Covered Employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child is no longer eligible for coverage under the plan as a “Dependent child.”

If this Plan provides retiree health coverage, sometimes, filing a proceeding in bankruptcy under Title 11 of the United States Code can be a Qualifying Event. If a proceeding in bankruptcy is filed with respect to the Employer, and that bankruptcy results in the loss of coverage of any retired Employee covered under the Plan, the retired Employee will become a Qualified Beneficiary with respect to the bankruptcy. The retired Employee’s Spouse, surviving Spouse, and Dependent children also will become Qualified Beneficiaries if bankruptcy results in the loss of their coverage under the Plan. The Employer must give notice of some Qualifying Events When the Qualifying Event is the end of employment, reduction of hours of employment, death of the Covered Employee, commencement of proceeding in bankruptcy with respect to the Employer, or the Covered Employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), the Plan Administrator must be notified of the Qualifying Event. You must give notice of some Qualifying Events Each Covered Employee or Qualified Beneficiary is responsible for providing the Plan Administrator with the following notices, in writing, either by U.S. First Class Mail or hand delivery: (1) Notice of the occurrence of a Qualifying Event that is a divorce or legal separation of a Covered Employee (or former Employee) from his

or her Spouse; (2) Notice of the occurrence of a Qualifying Event that is an individual’s ceasing to be eligible as a Dependent child under the terms of the

Plan;



(3) Notice of the occurrence of a second Qualifying Event after a Qualified Beneficiary has become entitled to COBRA Continuation Coverage with a maximum duration of 18 (or 29) months;

(4) Notice that a Qualified Beneficiary entitled to receive Continuation Coverage with a maximum duration of 18 months has been determined by the Social Security Administration (“SSA”) to be disabled at any time during the first 60 days of Continuation Coverage; and

(5) Notice that a Qualified Beneficiary, with respect to whom a notice described in (4) above has been provided, has subsequently been determined by the SSA to no longer be disabled.

Plan Administrator David Cram, Director of Business & Operations La Conner School District 305 North 6th Street La Conner, WA 98257 360‐466‐3171 A form of notice is available, free of charge, from the (Plan or COBRA) Administrator and must be used when providing the notice. Deadline for providing the notice For Qualifying Events described in (1), (2) or (3) above, the notice must be furnished by the date that is 60 days after the latest of:

• The date on which the relevant Qualifying Event occurs; • The date on which the Qualified Beneficiary loses (or would lose) coverage under the Plan as a result of the Qualifying Event; or • The date on which the Qualified Beneficiary is informed, through the furnishing of the Plan's SPD or the general notice, of both the

responsibility to provide the notice and the Plan's procedures for providing such notice to the Plan Administrator.

For the disability determination described in (4) above, the notice must be furnished by the date that is 60 days after the latest of:

• The date of the disability determination by the SSA; • The date on which a Qualifying Event occurs; • The date on which the Qualified Beneficiary loses (or would lose) coverage under the Plan as a result of the Qualifying Event; or • The date on which the Qualified Beneficiary is informed, through the furnishing of the Plan’s SPD or the general notice, of both the


In any event, this notice must be furnished before the end of the first 18 months of Continuation Coverage. For a change in disability status described in (5) above, the notice must be furnished by the date that is 30 days after the later of:

• The date of the final determination by the SSA that the Qualified Beneficiary is no longer disabled; or • The date on which the Qualified Beneficiary is informed, through the furnishing of the Plan's SPD or the general notice, of both the


The notice must be postmarked (if mailed), or received by the Plan Administrator (if hand delivered), by the deadline set forth above. If the notice is late, the opportunity to elect or extend COBRA Continuation Coverage is lost, and if you are electing COBRA Continuation Coverage, your coverage under the Plan will terminate on the last date for which you are eligible under the terms of the Plan, or if you are extending COBRA Continuation Coverage, such Coverage will end on the last day of the initial 18‐month COBRA coverage period. Who can provide the notice? Any individual who is the Covered Employee (or former Employee), a Qualified Beneficiary with respect to the Qualifying Event, or any representative acting on behalf of the Covered Employee (or former Employee) or Qualified Beneficiary, may provide the notice, and the provision of notice by one individual shall satisfy any responsibility to provide notice on behalf of all related Qualified Beneficiaries with respect to the Qualifying Event. Required contents of the notice. The notice must contain the following information:

• Name and address of the Covered Employee or former Employee; • If you already are receiving COBRA Continuation Coverage and wish to extend the maximum coverage period, identification of the initial

Qualifying Event and its date of occurrence;



• A description of the Qualifying Event (for example, divorce, legal separation, cessation of Dependent status, entitlement to Medicare by the Covered Employee or former Employee, death of the Covered Employee or former Employee, disability of a Qualified Beneficiary or loss of disability status);

• In the case of a Qualifying Event that is divorce or legal separation, name(s) and address(es) of Spouse and Dependent child(ren) covered under the Plan, date of divorce or legal separation, and a copy of the decree of divorce or legal separation;

• In the case of a Qualifying Event that is Medicare entitlement of the Covered Employee or former Employee (or in certain circumstances, the Spouse), date of entitlement, and name(s) and address(es) of Spouse and Dependent child(ren) covered under the Plan;

• In the case of a Qualifying Event that is a Dependent child’s cessation of Dependent status under the Plan, name and address of the child, reason the child ceased to be an eligible Dependent (for example, attained limiting age, lost student status, married or other);

• In the case of a Qualifying Event that is the death of the Covered Employee or former Employee, the date of death, and name(s) and address(es) of Spouse and Dependent child(ren) covered under the Plan;

• In the case of a Qualifying Event that is disability of a Qualified Beneficiary, name and address of the disabled Qualified Beneficiary, name(s) and address(es) of other family members covered under the Plan, the date the disability began, the date of the SSA’s determination, and a copy of the SSA’s Notice of Award letter;

• In the case of a Qualifying Event that is loss of disability status, name and address of the Qualified Beneficiary who is no longer disabled, name(s) and address(es) of other family members covered under the Plan, the date the disability ended and the date of the SSA’s determination; and

• A certification that the information is true and correct, a signature and date. If you cannot provide a copy of the decree of divorce, legal separation or the SSA’s Notice of Award letter by the deadline for providing the notice, complete and provide the notice, as instructed, by the deadline and submit the copy of the decree of divorce, legal separation, or the SSA’s Notice of Award letter within 30 days after the deadline. The notice will be timely if you do so. However, no COBRA Continuation Coverage, or extension of such Coverage, will be available until the copy of the decree of divorce or legal separation, or the SSA’s Notice of Award letter is provided. If the notice does not contain all of the required information, the Plan Administrator may request additional information. If the individual fails to provide such information within the time period specified by the Plan Administrator in the request, the Plan Administrator may reject the notice if it does not contain enough information for the Plan Administrator to identify the plan, the Covered Employee (or former Employee), the Qualified Beneficiaries, the Qualifying Event or disability, and the date on which the Qualifying Event, if any, occurred. Electing COBRA Continuation Coverage Complete instructions on how to elect COBRA Continuation Coverage will be provided by the COBRA Administrator within 14 days of receiving the notice of your Qualifying Event. You then have 60 days in which to elect COBRA Continuation Coverage. The 60‐day period is measured from the later of the date coverage terminates or the date of the notice containing the instructions. If COBRA Continuation Coverage is not elected in that 60‐day period, then the right to elect it ceases. 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 Coverage on behalf of their children. In the event that the COBRA Administrator determines that the individual is not entitled to COBRA Continuation Coverage, the COBRA Administrator will provide to the individual an explanation as to why he or she is not entitled to COBRA Continuation Coverage. How long does COBRA Continuation Coverage last? COBRA Continuation Coverage will be available up to the maximum time period shown below. Generally, multiple Qualifying Events which may be combined under COBRA will not continue coverage for more than 36 months beyond the date of the original Qualifying Event. However, if, pursuant to the Plan, the first Qualifying Event is the Covered Employee’s entitlement to Medicare benefits, followed by termination or reduction of hours, then the maximum coverage period for Qualified Beneficiaries other than the Covered Employee ends on the later of (i) 36 months after the date the Covered Employee became entitled to Medicare benefits, and (ii) 18 months (or 29 months if there is a disability extension) after the date of the termination or reduction of hours. For all other Qualifying Events, the continuation period is measured from the date of the Qualifying Event, not the date of loss of coverage. If, pursuant to the Plan, the Qualifying Event is the death of the Covered Employee (or former Employee), the Covered Employee’s (or former 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. If the Qualifying Event is the end of employment or reduction of the Covered Employee’s hours of employment, and the Covered Employee became entitled to Medicare benefits less than 18 months before the Qualifying Event, COBRA Continuation Coverage for Qualified Beneficiaries other than the Covered 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 (for reasons other than gross misconduct) or reduction of the Covered 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 COBRA Continuation Coverage If you or anyone in your family covered under the Plan is determined by the SSA to be disabled and you notify the Plan Administrator as set forth above, 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 COBRA Continuation Coverage. An extra fee will be charged for this extended COBRA Continuation Coverage. Second Qualifying Event extension of 18‐month period of COBRA 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 up to 18 additional months of COBRA Continuation Coverage, for a maximum of 36 months, if notice of the second Qualifying Event properly is given to the Plan as set forth above. This extension may be available to the Spouse and any Dependent children receiving COBRA Continuation Coverage if the Covered Employee or former Employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the Dependent child stops being eligible under the Plan as a Dependent child, but only if the event would have caused the Spouse or Dependent child to lose coverage under the Plan had the first Qualifying Event not occurred. Does COBRA Continuation Coverage ever end earlier than the maximum periods above? COBRA Continuation Coverage also may end before the end of the maximum period on the earliest of the following dates:

• The date your Employer ceases to provide a group health plan to any Employee; • The date on which coverage ceases by reason of the Qualified Beneficiary’s failure to make timely payment of any required premium; • The date that the Qualified Beneficiary first becomes, after the date of election, covered under any other group health plan (as an

Employee or otherwise), or entitled to either Medicare Part A or Part B (whichever comes first), except as stated under COBRA’s special bankruptcy rules. However, a Qualified Beneficiary who becomes covered under a group health plan which has a Pre‐Existing Condition limit must be allowed to continue COBRA Continuation Coverage for the length of a Pre‐Existing Condition or to the COBRA maximum time period, if less; or

• The first day of the month that begins more than 30 days after the date of the SSA’s determination that the Qualified Beneficiary is no longer disabled, but in no event before the end of the maximum coverage period that applied without taking into consideration the disability extension.

• On the same basis that the Plan can terminate for cause the coverage of a similarly situated non‐COBRA participant.

Payment for COBRA Continuation Coverage Once COBRA Continuation Coverage is elected, you must pay for the cost of the initial period of coverage within 45 days. Payments then are due on the first day of each month to continue coverage for that month. If a payment is not received and/or post‐marked within 30 days of the due date, COBRA Continuation Coverage will be canceled and will not be reinstated. This Plan shall be in compliance with the American Recovery and Reinvestment Act of 2009 (ARRA), in effect as of the first period of COBRA Continuation Coverage starting on or after February 17, 2009, and as amended from time to time. ARRA may reduce the COBRA premium in some cases. You may qualify for a premium reduction. This premium reduction may only continue for a limited time and you may be subject to certain eligibility restrictions and obligations. You should consult either the Plan Administrator or the COBRA Administrator if you have questions or if you believe you are eligible for a premium reduction. The Trade Act of 2002, as amended by ARRA, may affect the benefits received under COBRA. First, certain eligible individuals who lose their jobs due to international trade agreements may receive a tax credit for premiums paid for certain types of health insurance, including COBRA premiums. Second, eligible individuals under the Trade Act who do not elect COBRA Continuation Coverage within the election period will be allowed an additional 60‐day period to elect COBRA Continuation Coverage. If the Qualified Beneficiary elects COBRA Continuation Coverage during this second election period, the coverage period will run from the beginning date of the second election period. If you elect a tax credit under the Trade Act, you will not be eligible for other Federal COBRA premium subsidies which may be available. You should consult the Plan Administrator if you believe the Trade Act applies to you. Additional Information Additional information about the Plan and COBRA Continuation Coverage is available from the Plan Administrator and COBRA Administrator:



Plan Administrator La Conner School David Cram, Director of Business & Operations 305 North 6th Street La Conner, WA 98257 360‐466‐3171 COBRA Administrator La Conner School David Cram, Director of Business & Operations 305 North 6th Street

La Conner, WA 98257 360‐466‐3171 Current Addresses In order to protect your family’s rights, you should keep the Plan Administrator (who is identified above) informed of any changes in the addresses of family members. HIPAA PRIVACY AND SECURITY NOTICE STANDARDS FOR PRIVACY OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (THE “PRIVACY STANDARDS”) ISSUES PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996, AS AMENDED (HIPAA) Disclosure of Summary Health Information to the Plan Sponsor In accordance with the Privacy Standards, the Plan may disclose Summary Health Information to the Plan Sponsor, if the Plan Sponsor requests the Summary Health Information for the purpose of (a) obtaining premium bids from health plans for providing health insurance coverage under this Plan or (b) modifying, amending or terminating the Plan. “Summary Health Information” may be individually identifiable health information and it summarizes the claims history, claims expenses or the type of claims experienced by individuals in the plan, but it excludes all identifiers that must be removed for the information to be de‐identified, except that it may contain geographic information to the extent that it is aggregated by five‐digit zip code. Disclosure of Protected Health Information (PHI) to the Plan Sponsor for Plan Administration Purposes “Protected Health Information” (PHI) means individually identifiable health information, created or received by a health care provider, health plan, employer, or health care clearinghouse; and relates to the past, present, or future physical or Mental Health condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and is transmitted or maintained in any form or medium. In order that the Plan Sponsor may receive and use PHI for Plan Administration purposes, the Plan Sponsor agrees to:

1) Not use or further disclose PHI other than as permitted or required by the Plan Documents or as Required by Law (as defined in the Privacy Standards);

2) Ensure that any agents, including a subcontractor, to whom the Plan Sponsor provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Plan Sponsor with respect to such PHI;

3) Not use or disclose PHI for employment‐related actions and decisions or in connection with any other benefit or Employee benefit plan of the Plan Sponsor, except pursuant to an authorization which meets the requirements of the Privacy Standards;

4) Report to the Plan any PHI use or disclosure that is inconsistent with the uses or disclosures provided for of which the Plan Sponsor becomes aware;

5) Make available PHI in accordance with Section 164.524 of the Privacy Standards (45 CFR 164.524); 6) Make available PHI for amendment and incorporate any amendments to PHI in accordance with Section 164.526 of the Privacy Standards

(45 CFR 164.526); 7) Make available the information required to provide an accounting of disclosures in accordance with Section 164.528 of the Privacy

Standards (45 CFR 164.528); 8) Make its internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Secretary

of the U.S. Department of Health and Human Services (“HHS”), or any other officer or Employee of HHS to whom the authority involved has been delegated, for purposes of determining compliance by the Plan with Part 164, Subpart E, of the Privacy Standards (45 CFR 164.500 et seq);

9) If feasible, return or destroy all PHI received from the Plan that the Plan Sponsor still maintains in any form and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the PHI infeasible; and

10) Ensure that adequate separation between the Plan and the Plan Sponsor, as required in Section 164.504(f)(2)(iii) of the Privacy Standards (45 CFR 164.504(f)(2)(iii)), is established as follows:

a) The following Employees, or classes of Employees, or other persons under control of the Plan Sponsor, shall be given access to the PHI to be disclosed:



• An officer or Employee who serves as the Plan Administrator; • An officer or Employee who serves as a Plan fiduciary, and • An officer or Employee who performs functions related to the Plan, including but not limited to human relations,

audit, legal, accounting and systems personnel. b) The access to and use of PHI by the individuals described in subsection (a) above shall be restricted to the Plan Administration

functions that the Plan Sponsor performs for the Plan. c) In the event any of the individuals described in subsection (a) above do not comply with the provisions of the Plan Documents

relating to use and disclosure of PHI, the Plan Administrator shall impose reasonable sanctions as necessary, in its discretion, to ensure that no further non‐compliance occurs. Such sanctions shall be imposed progressively (for example, an oral warning, a written warning, time off without pay and termination), if appropriate, and shall be imposed so that they are commensurate with the severity of the violation.

"Plan Administration" activities are limited to activities that would meet the definition of payment or health care operations, but do not include functions to modify, amend or terminate the Plan or solicit bids from prospective issuers. "Plan Administration" functions include quality assurance, claims processing, auditing, monitoring and management of carve‐out plans, such as vision and dental. It does not include any employment‐related functions or functions in connection with any other benefit or benefit plans.

The Plan shall disclose PHI to the Plan Sponsor only upon receipt of a certification by the Plan Sponsor that (a) the Plan Documents have been amended to incorporate the above provisions and (b) the Plan Sponsor agrees to comply with such provisions. Disclosure of Certain Enrollment Information to the Plan Sponsor Pursuant to Section 164.504(f)(1)(iii) of the Privacy Standards (45 CFR 164.504(f)(1)(iii)), the Plan may disclose to the Plan Sponsor information on whether an individual is participating in the Plan or is enrolled in or has disenrolled from a health insurance issuer or health maintenance organization offered by the Plan to the Plan Sponsor. Other Disclosures and Uses of PHI With respect to all other uses and disclosures of PHI, the Plan shall comply with the Privacy Standards. STANDARDS FOR SECURITY OF ELECTRONIC PROTECTED HEALTH INFORMATION (THE “PRIVACY STANDARDS”) ISSUES PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996, AS AMENDED (HIPAA) Disclosure of Electronic Protected Health Information (“Electronic PHI”) to the Plan Sponsor for Plan Administration Functions To enable the Plan Sponsor to receive and use Electronic PHI for Plan Administration Functions (as defined in 45 CFR § 164.504(a)), the Plan Sponsor agrees to:

a) Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the Electronic PHI that it creates, receives, maintains, or transmits on behalf of the Plan;

b) Ensure that adequate separation between the Plan and the Plan Sponsor, as required in 45 CFR § 164.504(f)(2)(iii), is supported by reasonable and appropriate security measures.

c) Ensure that any agent, including a subcontractor, to whom the Plan Sponsor provides Electronic PHI created, received, maintained, or transmitted on behalf of the Plan, agrees to implement reasonable and appropriate security measures to protect the Electronic PHI; and

d) Report to the Plan any security incident of which it becomes aware. Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may, in the future, be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends and provide proof that coverage ended. Note: There can not be a break in coverage. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days of the marriage, birth, adoption, or placement for adoption.



Medicare Part D

Important Notice from La Conner School District About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with La Conner School District and prescription drug coverage available for people with Medicare. It also explains the options you have under Medicare prescription drug coverage and can help you decide whether or not you want to enroll. At the end of this notice is information about where you can get help to make decisions about your prescription drug coverage.

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug coverage. All Medicare prescription 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. La Conner School District has determined that the prescription drug coverage offered by the La Conner School District is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage.

Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare prescription drug coverage.

Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from November 15th through December 31st. Beneficiaries leaving employer/union coverage may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan.

You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area.

If you do decide to enroll in a Medicare prescription drug plan and drop your La Conner School District prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back.

Please contact us for more information about what happens to your coverage if you enroll in a Medicare prescription drug plan. You should also know that if you drop or lose your coverage with La Conner School District and don’t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later.

If you go 63 days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than what many other people pay. You’ll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to enroll.

For more information about this notice or your current prescription drug coverage… Contact the Benefits Department for further information. NOTE: You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage through La Conner School District changes. You also may request a copy.

For more information about your options under Medicare prescription drug coverage…

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 prescription drug plans. For more information about Medicare prescription drug plans:

• Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see 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.

For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www.socialsecurity.gov, or you may call them at 1‐800‐772‐1213 (TTY 1‐800‐325‐0778).

Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount.

Date: 10/01/2011 Name of Entity/Sender: La Conner School District Contact‐‐Position/Office: David Cram Address: 305 North 6th Street, La Conner, WA 98257 Phone Number: 360.466.3171



Benefits Summary Booklet€¦ · Bellevue, WA 98004 1‐866‐576‐0201 Deferred Comp Program...

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