PEBC Wellness Program

Summary Plan Description Public Employee Benefits Cooperative of North Texas (PEBC) Effective January 1, 2015

This booklet contains a description of the PEBC Wellness Program. You can also find information online at www.pebcinfo.com.

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This booklet describes the PEBC Wellness Program (the “Program”) offered by your Employer through the PEBC. This booklet is written in plain language to help you understand how the benefits work. In no event may any representations by any person change the terms of the Program. The PEBC intends to continue the Program indefinitely. However, it reserves the right to terminate or make changes to any benefit at any time, for any reason. Your participation in this Program is not a contract or guarantee of employment. Also, this Program and its coverage are not a plan of Workers’ Compensation coverage. Check with your Employer to determine whether they subscribe to the Workers’ Compensation System. Further, the relationship between your Employer, the Program, and any services provided by medical plan network providers is one of independent contracting entities. Participating providers are not agents or employees of the Program, of the PEBC, or of your Employer. All providers will maintain the physician-patient or professional provider-patient relationship with you and are the only parties responsible to you for the services they provide. No Program representative shall be deemed to be engaged in the practice of medicine, nor shall they supervise the practice of medicine by any participating provider. Finally, no Program representative will supervise, regulate, or interfere with the usual professional relationships between a provider and a covered person.

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Table of Contents The PEBC Wellness Program ....................................................................................................... 3 Eligibility and Registration ........................................................................................................... 4 How to Earn Wellness Points ....................................................................................................... 7 Receiving a Wellness Reward ...................................................................................................... 12 Notices .......................................................................................................................................... 13 Privacy of Your Information Notice of Privacy Practices ...................................................................................................... 15 PEBC Privacy Policy ............................................................................................................... 19 Administrative Information .......................................................................................................... 22 What is the Public Employee Benefits Cooperative of North Texas (PEBC)? Faced with increasing medical costs, in 1998 Dallas and Tarrant Counties banded together to form a regional cooperative program, called the Public Employee Benefits Cooperative of North Texas (PEBC), to help generate savings in their employee health-benefits programs. One year later, the North Texas Tollway Authority joined the PEBC to leverage cost savings to its employee health plan. Denton County joined the cooperative effective January 1, 2003, and the PEBC welcomed its newest employer group, Parker County, on January 1, 2010. The member governments of the PEBC are dedicated to offering choice, flexibility and value as we strive to manage costs in an era of double-digit health care cost increases. Through the PEBC, the member governments work diligently to keep benefits costs affordable. The PEBC provides many services, including joint purchase of employee benefits and cost-effective, centralized administration. With current economic conditions and the rapidly rising cost of health care, benefits of PEBC membership are even more valuable today.

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The PEBC Wellness Program The PEBC Wellness Program began January 1, 2015 as a way to promote a culture of better health. The Wellness Program is a Participation Model wellness plan. This booklet explains how the Program works. Here is a quick overview of the Program: • Active employees enrolled in either the PEBC PPO Medical Plan or the PEBC HDP Medical

Plan can earn a $300 reward by earning wellness points. This is an annual reward, and an employee cannot receive more than one $300 reward per calendar year.

• To earn a reward, employees must first register online at myuhc.com. • To earn the $300 reward, an employee must earn 300 points through the options described in

this booklet. Points are not prorated, and partial points do not count.

• Points must be earned during the reward earning period of January 1 through October 31 of any calendar year.

• An online Health Assessment at myuhc.com must be completed each year before getting

credit for additional wellness points earned.

• Rewards are paid out three (3) times per year based on the earnings period in which the employee reaches the 300-point requirement. You must be an active employee at the time of payout in order to receive a wellness reward.

• The default payment method for the $300 reward is a cash payment included in a payroll

check. For PEBC County member groups only, employees may choose to have the reward deposited in a health care flexible spending account (FSA) or in a health savings account (HSA), subject to the rules and limits of the FSA or HSA.

• Employees who opt-out of PEBC medical plan coverage may access the wellness portal, take

the health assessment and participate in activities, but are not eligible to earn points or dollar rewards.

• Effective January 1, 2016, the program allows employees to earn additional rewards if the

employee’s spouse, who is covered by a PEBC medical plan, earns 300 wellness points.

• Additional outcomes may be required in future years as well, so it’s best to start now!

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Eligibility and Registration Eligibility You’re eligible to earn a monetary reward through the PEBC Wellness Program if you meet all of the following requirements: • You are an active employee; or • You are the covered spouse of an active employee (effective January 1, 2016); and • You are enrolled in either the PEBC PPO Medical Plan or the PEBC HDP Medical Plan;

and • You are registered at myuhc.com. You must earn the full 300 points during a time period when all of the above conditions are satisfied. Active employees include regular, full-time employees actively working for your Employer. Regular, part-time employees may be eligible for the Program if you Employer offers medical plan benefits to part-time employees. See the Employment Policies of your Employer for more details. The Summary Plan Descriptions for the PEBC PPO Medical Plan and the PEBC HDP Medical Plan contain a detailed description of the eligibility and enrollment requirements for active employees and spouses for those health plans. Retired employees and terminated employees maintaining PEBC medical plan coverage through COBRA are not eligible to earn rewards through this Program. For example, if you earn 150 points while you are an active employee enrolled in a PEBC medical plan but then terminate your employment, you are no longer eligible to earn a wellness program reward for you or your spouse, even if you continue PEBC medical plan coverage through COBRA. As a retired employee or COBRA member enrolled in the PEBC PPO or HDP medical plan, you may be eligible to utilize the wellness site in the same manner as an employee who opted-out of medical coverage. Employees who are temporarily away from work due to a vacation, disability or approved leave of absence, and who maintain their PEBC medical plan coverage, are considered to be active employees eligible for the PEBC Wellness Program. This includes employees on approved Family and Medical Leave Act (FMLA) leave, whether paid or unpaid, as long as PEBC medical plan coverage is maintained through active employee coverage (i.e., not through COBRA continuation coverage or retiree medical coverage). Opt-out Employees Employees who opt-out of PEBC medical plan coverage may access the wellness portal, take the health assessment and participate in activities, but are not eligible to earn points or dollar rewards.

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Covered Spouses and Other Dependents Beginning January 1, 2016, employees can also earn rewards for spouses enrolled in a PEBC medical plan. Other dependents covered under the PEBC medical plans are not eligible to earn monetary rewards. Registration with myuhc.com You must register at myuhc.com in order to earn points and rewards. Those enrolled in the PEBC PPO or HDP Medical Plans can log in at myuhc.com and select the Health and Wellness tab to register. Most of your information will be pre-populated by the site. Employees who opt-out of the PEBC medical plans can still access the wellness portal but are not eligible to earn points or dollar rewards. Opt-out employees have their own, unique registration log-in available from the employer. When Eligibility Ends Eligibility to earn credits under the PEBC Wellness Program ends on the earliest of the following dates: • The date employment ends due to resignation, participation in a strike, layoff, retirement,

expiration of an approved leave of absence, failure to return from a leave of absence, or termination of employment for any other reason;

• The date coverage under a PEBC medical plan ends for any reason; or • The date the Program ends (which includes the last day of the month in which the

Employer’s PEBC participation ends).

You must earn the full 300 points during a time period when you are both an active employee and covered by a PEBC medical plan. If you have a break in eligibility to earn wellness points, for example due to termination and rehire during a calendar year, any PEBC Wellness Program credits earned while you were eligible will be restored if you later return to active employment during the same calendar year. PEBC Wellness Program credits do not, however, carry over from one calendar year to the next and do not transfer from one PEBC employer to another PEBC employer, even if both participate in the PEBC Wellness Program. FMLA Leave If you have worked for your Employer at least 1,250 hours over the previous 12-month period and have at least 12 months of service, you may be eligible for up to 12 weeks of leave under the Family and Medical Leave Act (FMLA). If you are eligible for an FMLA leave, your medical plan coverage can continue for up to 12 weeks if you make the required payments subject to your Employer’s policy on FMLA leave.

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An FMLA leave may be granted for any of these reasons: • Birth of your child and care of your newborn child;

• Placement of a child with you (including a foster child) and care for your child after adoption or placement;

• Care for your spouse, child, or parent who has a serious health condition; or

• Your own serious health condition, when you are unable to perform your job. If you are on an FMLA leave on the day your PEBC medical plan coverage would otherwise begin, the medical plan will consider you to be actively at work. This means that PEBC medical coverage can begin for you, and you will also be eligible to earn rewards through the PEBC Wellness Program. See the “FMLA Leave” section of your medical plan booklet for more information about continuing medical plan coverage during an FMLA leave of absence, whether it is paid or unpaid leave. As long as your PEBC medical plan coverage continues, you will remain eligible to earn rewards through the PEBC Wellness Program. If your PEBC medical plan coverage ends, or if your employment terminates, your eligibility to earn wellness rewards through this Program will also end.

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How to Earn Wellness Points There are many ways to earn wellness points. Getting started is the key to earning points, and the earlier the better since timing is a factor in qualifying for a reward. Wellness Point Totals In order to receive a monetary wellness reward, you must earn 300 wellness points from the activities described in this section during the required timeframe. Partial points do not count. You must earn a full 300 points to qualify for any reward. An employee can earn a $300 reward for the employee achieving 300 points, or, beginning in 2016, a $600 reward if both the employee and the covered spouse each achieve 300 points (600 points total). Spouse points will not be paid unless the employee earns 300 points. The spouse must be enrolled in a PEBC medical plan and enrolled in the Wellness Program to participate, and remain enrolled at the time of payout for the additional reward payout. An illustration of spouse earned points is shown below. • If the employee did not earn 300 points but the covered spouse did, a reward will not be paid. • When the employee earns 300 points and the covered spouse did not, a $300 reward will be

paid to the employee (subject to payout rules described in this plan). • If a spouse earned 300 points, and as long as the employee earned 300 points, a total of $600

in rewards will be paid to the employee for the year (note: the spouse award does not apply for 2015).

• The selected payout method must be the same during the year if the rewards are paid at different payout intervals.

Timing to Earn Points In order to earn a monetary reward, points must be earned during the rewards earning period which begins on January 1 and ends October 31 of any calendar year. You cannot earn points for activities completed before January 1 or after October 31. Some of the activities listed in this section, such as certain telephonic or online activities, may take at least five or six weeks to complete before points are earned. Keep in mind this timing requirement, since all activities must be completed by October 31 in order for points to be earned. For example, if you begin a five-week online learning module on October 1, it will not earn points to qualify towards a reward, since you will not be able to complete the module by October 31. For those activities that earn rewards based on a medical visit, biometric screening or preventive cancer screening, the wellness points are not available until the provider submits the claim, and the claim is processed and paid. It can take several weeks for the points to be viewable.

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Online Health Assessment Taking an online Health Assessment (a health survey) is a baseline activity which must be completed each year before you can be credited for other wellness points. In 2015, you can earn 100 points for the Health Assessment. Beginning in 2016, you can earn 75 points for the Health Assessment. The online Health Assessment can be found at myuhc.com and takes approximately 15 minutes to complete. Reward Activities to Earn Points Once you have completed the online Health Assessment, you can earn additional wellness points from the following activities. If you are visiting your doctor’s office for preventive services only in order to earn wellness points, make sure you share that information with your doctor’s office. • Annual Physical – Earn 25 points (once each year) for your annual physical. A physical

performed at your doctor’s office will automatically reflect points earned once the claim is paid. You must be 18 years or older to earn points for an annual physical.

• Biometric Screening – Earn points (once each year) by having your doctor identify your

biometrics (cholesterol, blood sugar, etc.) during a health provider office visit. You can earn 150 points for a biometric screening. Biometrics performed at your health provider’s office will automatically reflect points earned once the claim is paid. As an alternative, some employers may sponsor a biometric screening event at work, and you can earn points at those events as well. Your employer will provide additional information about scheduled events that are eligible for PEBC wellness points.

• Preventive Cancer Screenings – Earn 25 points (once each year) for a mammogram, a

colonoscopy or a cervical screening (one screening per year earns points) performed by your health care provider based on recommended screening guidelines for your age and gender. Preventive screenings performed at your health provider’s office will automatically reflect points earned once the claim is paid.

• Healthy Pregnancy – Earn 50 points when you enroll in UnitedHealthcare’s Healthy

Pregnancy Program. Although it is best to enroll in the program during your first trimester, you can enroll at any time during your pregnancy, up through your 34th week of pregnancy. To enroll in the Healthy Pregnancy Program, call 800-411-7984 (Monday – Saturday). For more information, visit www.healthy-pregnancy.com. Wellness points will be credited upon enrollment in the program as determined by UnitedHealthcare.

• Online Learning Modules – Earn 50 points (once each year) for completion of an online

learning wellness module found at myuhc.com. You are free to choose the program that fits your wellness goal. Each program can take a minimum of five (5) weeks to complete. Based on your Health Assessment results, your interactive health coach may suggest health improvement programs to help you achieve your personal health goals.

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• Telephonic Learning Modules – Earn 50 points (once each year) for completion of a telephonic learning wellness module found at myuhc.com. Each program is adjusted to fit your needs, so the number of sessions will be determined by you and your assigned coach. Each phone call lasts 20-30 minutes and can be spaced out over three to six months. You must complete the module to earn wellness points. There are a variety of available telephonic learning modules at myuhc.com. Examples of

two of the most popular modules are the QuitPower © and Healthy Weight programs: - QuitPower © (tobacco cessation) – This is an enhanced phone-based tobacco cessation

program that lets you work with your own personal coach who can help you quit tobacco and live a healthier life. You and your coach will work together to help you reach your goal. You may also qualify to receive up to eight weeks of nicotine replacement therapy (such as patches, gum, etc.) at no extra cost.

- Healthy Weight – Your coach specializes in healthy weight loss, providing answers, support and motivation to help you achieve your weight loss goals.

- Healthy Pregnancy Program – You can also earn points by participating in telephonic coaching through the Healthy Pregnancy Program (described above separately; maximum 50 points for this program per year).

• Disease Management – If you are qualified for a disease management as a result of a chronic condition and you are contacted by a UnitedHealthcare nurse, you can earn up to 100 points for participating in the disease management program.

• Employer Track – As long as the Employer Track feature is available and as long as your

employer participates in the Employer Track, you can earn up to 25 points for completing health/life learning activities (such as Weight Watchers at Work, etc.) and/or fitness or other wellness activities. You can complete Employer Track activities up to two times each year to earn up to 50 total points. Not all employers participate, but if your employer does, you will receive more information about the Employer Track directly from your employer. The availability of Employer Track is subject to change.

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Summary Chart – Earning Wellness Points The following chart summarizes how to earn wellness points. Wellness Points Needed: 300 Timeframe: January 1 – October 31 Activity

Points and Frequency Notes

1 Health Assessment (online at myuhc.com)

2015: 100 points, once per year 2016: 75 points, once per year

MUST BE COMPLETED EACH YEAR TO EARN ADDITIONAL POINTS

2 Annual Physical

25 points, once per year

3 Biometric Screening

150 points, once per year

4 Preventive Cancer Screenings

25 points, once per year Choose from a Mammogram, colonscopy or cervical screening. Tests are based on age/gender

5 Healthy Pregnancy Program

50 points, once per year

6 Online Learning Modules 50 points, once per year Points earned upon completion. Requires at least 5 weeks.

7 Telephonic Learning Modules

50 points, once per year Points earned upon completion. May take 3-6 months to complete.

8 Disease Management Program

100 points, once per year UnitedHealthcare determines eligibility for disease management

9 Employer Track

25 points, twice per year (up to 50 total points)

As long as available and only available from participating employers

Tracking Wellness Points For most of the activities to earn Wellness Program credits, UnitedHealthcare will automatically credit the employee’s wellness account with the appropriate points earned. For points earned under the Employer Track, if your Employer participates, the Employer is responsible for determining the number of points earned and submitting the information for credit. You can check the status of Wellness Program credits earned through the wellness portal at www.myuhc.com. Except for Employer Track questions, you should direct any questions regarding points earned to Optum (part of UnitedHealthcare) at 1-877-818-5826.

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Confidentiality Your employer does not have access to your confidential health information submitted through the online Health Assessment nor provided through any of the Learning Modules or other programs above (with the exception of Employer Track information, which may be collected by your employer). The information you enter into the UnitedHealthcare system is secure, safe and protected.

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Receiving a Wellness Reward The wellness reward is a $300 annual reward per person, for the employee and, beginning in 2016, spouse covered under a PEBC medical plan. The maximum annual reward is $600. To earn the reward, you must earn 300 wellness points within the defined timeframe of January 1 through October 31 as described in this booklet. Partial points do not count, and there is no proration of the reward for points earned below 300. Partial points do not carry over from one calendar year to the next and do not transfer from one employer to another. You may only earn one $300 reward for you and one $300 reward for your spouse (total reward not to exceed $600) each calendar year. The UnitedHealthcare wellness portal, available to you at myuhc.com, will keep track of wellness points earned throughout the year. The dollar amount of wellness rewards available under this Program is less than 30% of the total cost of employee-only coverage under the PEBC medical plans. Payment of the Reward The default payment method for the wellness reward is cash, which means the funds will be included in a payroll check on a post-tax basis. For PEBC County participants only, you can choose to have your reward deposited to your health care flexible spending account (FSA) or your health savings account (HSA), subject to the underlying rules for an FSA and HSA. You will receive more information about your payment options when you qualify for the reward. Timing of Reward Payments Rewards are paid three (3) times during the year based on when you reach the 300-point threshold. You must be an active employee at the time the reward is paid in order to receive a reward. You cannot receive more than one reward each year. • Reach 300 points earned January 1 – March 31: paid by May 31 • Reach 300 points earned January 1 – June 30: paid by August 31

• Reach 300 points earned January 1 – October 31: paid by December 31

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Notices The PEBC Wellness Program provides a benefit to eligible employees for themselves and, beginning in 2016, for eligible enrolled spouses, who complete wellness-related activities as described in this booklet. It is not a comprehensive group medical plan and does not provide any coverage for medical services received. While employees may earn credits through the Wellness Program for certain medical services received, such as preventive services or disease management, the cost of those services and any reimbursement for them applies to the PEBC medical plan in which the employee is enrolled, and not to the PEBC Wellness Program. The following health plan-related requirements do not apply to the PEBC Wellness Program since the Program does not provide reimbursement for any medical services: 1. Hospital stays for mothers and newborns. 2. Parity in the application of certain limits to mental health benefits. 3. Mandated reconstructive surgery benefits following mastectomy. 4. Coverage of dependent students on medically necessary leave of absence. Voluntary Program The PEBC Wellness Program is a voluntary program. Employees are not required to participate in the Program. PEBC Employers will not deny access to health coverage or generally limit coverage under the PEBC medical plans for non-participation in the Wellness Program. In addition, PEBC Employers will not take any other adverse action or retaliate against, interfere with, coerce, intimidate, or threaten employees (such as by threatening to discipline an employee who does not participate or who fails to achieve certain health outcomes) regarding the Wellness Program. No Extension of Program Participation Eligibility for the PEBC Wellness Program ends when the employee is no longer an active employee or ceases to participate in a PEBC medical plan, whichever comes first. There is no extension or continuation of coverage (for example, through COBRA) of PEBC Wellness Program credits or rewards. Claims and Appeals Any claims for medical services received should be submitted through the appropriate PEBC medical plan. The PEBC Wellness Program does not provide coverage nor reimbursement for medical services received, and as such there are no claim forms, and no claims and appeals processes. The claims and appeals processes of the underlying PEBC medical plans apply to those services. For most of the activities to earn Wellness Program credits, UnitedHealthcare will automatically credit the employee’s wellness account with the appropriate points earned. For points earned

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under the Employer Track, if your Employer participates, the Employer is responsible for determining the number of points earned and submitting the information to the PEBC for credit. Except for Employer Track questions, you should direct any questions regarding points earned to Optum (part of UnitedHealthcare) at 1-877-818-5826. Time Limit for Legal Action You cannot bring any legal action against the Plan Sponsor, your Employer or the Claims Administrator (Optum/UnitedHealthcare) to receive wellness rewards until after you have contacted Optum/UnitedHealthcare and followed their procedures regarding documentation of wellness information. Unless otherwise permitted by applicable law, you may not take legal action against the Program or a Program fiduciary for failure to receive a reward more than three years from the date your employment ends or you fail to receive a wellness reward, if earlier. Your usage of the Program represents your stipulation that the time within which to bring suit is three years from the applicable date. Right of Recovery If for some reason a reward is paid which is larger than the amount allowed by the Program, or violates FSA or HSA rules and limits, the Program has a right to recover the excess amount from the person or agency that received it. The person receiving benefits must produce any instruments or papers necessary to ensure this right of recovery, unless prohibited by law.

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Privacy of Your Information

NOTICE OF PRIVACY PRACTICES PEBC Group Health Plans

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Effective Date of Notice: September 23, 2013. The “Plan” as described below refers to all PEBC group health plans, including the HDP Medical Plan, EPO Medical Plan, PPO Medical Plan, PEBC Dental Plan, PEBC Vision Plan, and Health Care Spending Accounts (both general and limited purpose) if offered by your Employer. "You" or "yours" refers to individual participants in the Plan. If you are covered by a PEBC dental HMO plan, you will receive a separate notice from that HMO. Throughout this document are references to the “Plan” and its administration. With regard to health plans offered on a fully insured basis (e.g., dental HMO and vision), information received from the “Plan” will generally be coming from the insurer on behalf of the Plan. For self-funded plans, “Plan” administration includes your Employer’s own internal administration of the Plan, as well as PEBC and other administration activities. Use and Disclosure of Protected Health Information The Plan is required by federal law to protect the privacy of your individual health information (referred to in this Notice as "Protected Health Information"). The Plan is also required to provide you with this Notice regarding policies and procedures regarding your Protected Health Information, and to abide by the terms of this Notice, as it may be updated from time to time. Under applicable law, the Plan is permitted to make certain types of uses and disclosures of your Protected Health Information, without your authorization, for treatment, payment and health care operations purposes. For treatment purposes, routine use and disclosure may include providing, coordinating or managing health care and related services by one or more of your providers, such as when your primary care physician consults with a specialist regarding your condition. For payment purposes, use and disclosure of your information may take place to determine responsibility for coverage and benefits, such as when the Plan checks with other health plans to resolve a coordination of benefits issue. The Plan also may use your Protected Health Information for other payment-related purposes, such as to assist in making plan eligibility and coverage determinations, or for utilization review activities. Payment purposes may also include, but is not limited to, billing, claims management, subrogation, reviews for medical necessity, utilization review and pre-authorizations.

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For health care operations purposes, use and disclosure may take place in a number of ways involving plan administration, including for quality assessment and improvement, vendor review, and underwriting activities. Your information could be used, for example, to assist in the evaluation of one or more vendors who support the Plan, or our vendors may contact you to provide reminders or information about treatment alternatives or other health-related benefits and services available under the Plan. Health care operations may also include, but are not limited to, disease management, case management, legal reviews, handling appeals and grievances, plan or claims audits, fraud and abuse compliance programs, and other general administrative activities. The Plans covered by this Notice may share PHI with each other as necessary to carry out treatment, payment, or health care operations. For example, your requests for claim payment may automatically be sent from a PEBC Medical Plan to the Health Care Spending Account Plan, in order to simplify and accelerate claims payment. The Plans may contract with individuals or entities known as Business Associates to perform various functions on the Plans’ behalf or to provide certain types of services. In order to perform these functions or to provide these services, Business Associates will receive, create, maintain, use and/or disclose your Protected Health Information. For example, we may disclose your Protected Health Information to a Business Associate to administer claims or to provide support services, such as utilization management, pharmacy benefit management or subrogation, but only after the Business Associate enters into a Business Associate Agreement with us. The Business Associate Agreement obligates each Business Associate to protect the privacy of your information, and Business Associates are not allowed to use or disclose any information other than as specified in our contract for services. The Plan may disclose your Protected Health Information to the Employer that sponsors this Plan and to the PEBC in connection with these activities. The Plan does not use or disclose your Protected Health Information for employment-related actions, such as hiring or termination, or for any other purposes not authorized by the HIPAA privacy regulations. If you are covered under an insured health plan, such as a dental HMO, the insurer also may disclose Protected Health Information to the Employer that sponsors the Plan and to the PEBC in connection with payment, treatment or health care operations. The Plan is prohibited from using or disclosing genetic information for underwriting purposes, and will not use or disclose any of your Protected Health Information which contains genetic information for underwriting purposes. In addition, the Plan may use or disclose your Protected Health Information without your authorization under conditions specified in federal regulations, including: • As required by law, provided the use or disclosure complies with and is limited to the

relevant requirements of such law; • For public health activities; • To an appropriate government authority regarding victims of abuse, neglect or domestic

violence;

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• To a health oversight agency for oversight activities authorized by law; • In connection with judicial and administrative proceedings; • To a law enforcement official for law enforcement purposes; • To a coroner or medical examiner; • To cadaveric organ, eye or tissue donation programs; • For research purposes, as long as certain privacy-related standards are satisfied; • To avert a serious threat to health or safety; • For specialized government functions (e.g., military and veterans activities, national security

and intelligence, federal protective services, medical suitability determinations, correctional institutions and other law enforcement custodial situations); and

• For workers compensation or other similar programs established by law that provide benefits for work-related injuries or illness without regard to fault.

In special situations, the Plan may disclose to one of your family members, to a relative, to a close personal friend or to any other person identified by you, Protected Health Information that is directly relevant to the person's involvement with your care or payment related to your care. In addition, the Plan may use or disclose the Protected Health Information to notify a member of your family, your personal representative, another person responsible for your care, or certain disaster relief agencies of your location, general condition or death. If you are incapacitated, there is an emergency, or you otherwise do not have the opportunity to agree to or object to this use or disclosure, those involved in Plan administration will do what in our judgment is in your best interest regarding such disclosure and will disclose only the information that is directly relevant to the person's involvement with your health care. Uses and Disclosures for which an Authorization is Required Your authorization is required for most uses and disclosures of psychotherapy notes, uses and disclosures of Protected Health Information for marketing purposes, and disclosures which constitute a sale of Protected Health Information. We will make any other uses and disclosures not described in this Notice only after you authorize them in writing. You may revoke your authorization in writing at any time, except to the extent that we have already taken action in reliance on the authorization. Your Rights Regarding Protected Health Information You have the right to: • Inspect and Copy your Protected Health Information: Upon written request, you have the

right to inspect and get copies of your Protected Health Information (and that of an individual for whom you are a legal guardian). There are some limited exceptions.

• Request an Amendment: You have the right to amend or correct inaccurate or incomplete

Protected Health Information. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.

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• Receive An Accounting of Non-Routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your Protected Health Information. However, you are not entitled to an accounting of several types of disclosures including, but not limited to: - Disclosures made for payment, treatment or health care operations; - Disclosures you authorized in writing; or - Disclosures made before April 14, 2003.

• Request Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your Protected Health Information as we carry out payment, treatment, or health care operations. You may also ask us to restrict how we use and disclose your Protected Health Information to your family members, relatives, friends or other persons you identify who are involved in your care or payment for your care. We do not have to agree to these additional restrictions, but if we do, we must abide by our agreement (except in emergencies).

• Request Confidential Communications: You may request to receive your Protected Health

Information by alternative means or at an alternative location if you reasonably believe that other disclosure could pose a danger to you. For example, you may want to have Protected Health Information sent only by mail or to an address other than your home.

• Receive Notice of a Breach: You have the right to be notified upon a breach of your

unsecured Protected Health Information, if a disclosure occurs that meets the definition and thresholds of a breach under the law.

• Receive a Paper Copy of This Notice: You have the right to a paper copy of this Notice, even

if you have agreed to receive this notice electronically.

For more information about exercising these rights, contact the office at the end of this Notice. About This Notice The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all Protected Health Information maintained. If this Notice is changed, you will receive a new Notice by mail or by a Notice posted on the PEBC website, at www.pebcinfo.com. If you believe that your privacy rights have been violated, or that the privacy or security of your unsecured Protected Health Information has been compromised, you may file a complaint. You may complain in writing at the location described below under “Contacting the Plan Administrator” or to the U.S. Department of Health and Human Services, Office for Civil Rights, Region VI, at 1301 Young Street, Suite 1169, Dallas, TX 75202. You will not be retaliated against for filing a complaint.

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Contacting the Plan Administrator You may exercise the rights described in this Notice by contacting the office identified below. They will provide you with additional information. The contact is: PEBC PO Box 5888 Arlington, TX 76005-5888 817-608-2317

PEBC Privacy Policy This Privacy Policy applies to all PEBC health plans, including fully insured and self-funded plans. Throughout this document are references to the “Plan” and its administration. With regard to health plans offered on a fully insured basis (e.g., dental HMO and vision), information received from the “Plan” will generally be coming from the insurer on behalf of the Plan. For self-funded plans, “Plan” administration includes the Employer’s own internal administration of the Plan, as well as PEBC and other administration activities. Permitted Use and Disclosure of Protected Health Information Your Employer may only use and disclose protected health information it receives from the PEBC and from this Plan as permitted and/or required by, and consistent with, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its accompanying Privacy and Security regulations (found at 45 CFR Part 164). This includes, but is not limited to, the right to use and disclose a participant's protected health information, including electronic protected health information, in connection with payment, treatment and health care operations. The Plan and the PEBC will disclose protected health information to your Employer only upon receipt of a certification by the Employer that the Plan documents have been amended and adopted to incorporate all the required provisions as described below. Your Employer agrees to:

• Not use or further disclose protected health information other than as permitted or required

by the Plan documents for this Plan or as required by law;

• Ensure that any agent agrees to the same restrictions and conditions that apply to the Employer with respect to such information. For example, a subcontractor to whom the Employer gives protected health information received from the Plan must agree to the same

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restrictions and conditions that apply to the Employer with respect to protecting such information;

• Not use or disclose the information for employment-related actions and decisions;

• Not use or disclose the information in connection with any other benefit or employee benefit plan of the Employer unless authorized by the individual;

• Report to the PEBC, on behalf of the Plan, any use or disclosure of protected health information which the Employer becomes aware of that is inconsistent with the permitted uses or disclosures;

• Make protected health information available to an individual in accordance with the HIPAA Privacy rule’s access requirements, through processes coordinated by the PEBC;

• Make protected health information available for amendment through processes set up by the PEBC and incorporate any amendments to protected health information consistent with the HIPAA Privacy rules;

• Make available the information required to provide an accounting of disclosures in accordance with the HIPAA Privacy rules, following processes established by the PEBC;

• Make its internal practices, books and records relating to the use and disclosure of protected health information received from the Plan available to the Secretary of Health and Human Services and to the PEBC for purposes of determining the Plan’s compliance with the HIPAA Privacy rules;

• Not retain copies of protected health information when no longer needed for the purpose for which disclosure was made. If feasible, the Employer will return to the Plan or destroy all protected health information received from the Plan that the Employer still maintains in any form. An exception may apply if returning or destroying information is not feasible, but the Employer must limit further uses and disclosures to those purposes that make the return or destruction of the information not feasible.

Effective April 21, 2005 (the effective date of the Security rules), your Employer agrees to:

• Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the electronic protected health information that it creates, receives, maintains, or transmits on behalf of the Plan;

• Ensure that any agent to whom it gives electronic protected health information agrees to implement reasonable and appropriate security measures to protect such information;

• Report to the PEBC, on behalf of the Plan, any security incident involving electronic protected health information of which the Employer becomes aware.

Separation of the Employer and the Group Health Plan In accordance with HIPAA, only the following classes of employees or other persons may be given access to protected health information:

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• PEBC Executive Director and Executive Director’s authorized staff;

• The Plan’s Privacy Officer and Security Officer;

• The Employer’s authorized staff for management and administration of employee benefits, which may include Human Resources Department individuals;

• Financial, operations and eligibility personnel responsible for managing the accuracy of eligibility and payments required under the Plan;

• Members of the committee and governing body that reviews and makes decisions on claim denials, appeals and grievances; and

• Information technology personnel, including network administrators, who maintain human resource and benefits systems, e-mail systems, voicemail systems, or other information transmission systems used to transmit, store or manage protected health information.

The persons described above may only have access to and use and disclose protected health information for plan administration functions that the Employer performs for the Plan, or which the PEBC performs on behalf of the Employer. Except as permitted by the HIPAA Privacy rules, no other persons shall have access to protected health information. Effective April 21, 2005, the Employer shall ensure that the separation between the Plan and the Employer is supported by reasonable and appropriate security measures. The Employer shall provide an effective mechanism for resolving any issues of noncompliance by such employees or persons. The Employer will comply with PEBC policies and procedures to safeguard protected health information, including reporting issues of noncompliance to the PEBC Executive Director. If the persons described above do not comply with this Plan document, the Employer shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions. Policy Revision Effective Date: January 1, 2010

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Administrative Information This Program is a non-federal governmental self-funded plan not subject to the provisions of the Employee Retirement Income Security Act of 1974 (ERISA). Assignment of Benefits Your benefits belong to you and, under most circumstances, may not be sold, assigned, transferred, pledged, or garnished. If you cannot handle your financial affairs, any payments due may be paid to someone (such as a relative or court-appointed guardian) who is authorized to conduct your affairs. Clerical Error If a clerical error is inadvertently made which affects the administration of benefits under this Program, such an error will not nullify or change any of the terms, provisions or benefits available under this Program. Plan Year The Plan (Program) year is the same as the calendar year – January 1 to December 31. Plan Sponsor The Plan (Program) Sponsor is your Employer. Plan Administrator The Plan Administrator has the authority to interpret the Program provisions and exercise discretion where necessary. For the PEBC Wellness Program, the Plan Administrator is: Public Employee Benefits Cooperative of North Texas (PEBC) 616 Six Flags Drive Arlington, TX 76011 (817) 695-9141 External Administrator The External Administrator tracks wellness program reward credits earned for each employee. For the PEBC Wellness Program, the External Administrator is: Optum/UnitedHealthcare (877) 818-5826 If the Program Ends or Is Modified The PEBC and your Employer intend to continue this Program indefinitely. However, because conditions might change unexpectedly, the PEBC and your Employer reserve the right to change, suspend, or end the Program at any time, in whole or in part.

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In addition, rewards may be discontinued at any time for any group of employees or inactive participants. In the event that the Program is discontinued or terminated, in whole or in part, rewards would be paid only for credits received up to the date of Program termination. You will be notified if the Program is amended or terminated.