Fillable Newly-eligible-employees FR.008 - Health Benefits Enrollment Form For Newly Eligible Employees

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Newly-eligible-employees FR.008 - Health Benefits Enrollment Form For Newly Eligible Employees

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HEALTH BENEFITS ENROLLMENT FORM FOR NEWLY
ELIGIBLE EMPLOYEES
FR.008
It is your responsibility to complete and submit this form to the UCPath Center by 5pm PST on the 31st day of your PIE. See instructions sheet.
Required fields outlined in red must be completed in order for your form to be processed. Click to access form instructions.
1. PERSONAL INFORMATION Enter your information. Your UCPath Employee ID# is provided in your new hire paperwork.
First Name
Middle Initial
Employee ID Number
2. ELIGIBILITY EVENT Select your eligibility event. See A Complete Guide to Your UC Benefits for more details.
New Hire Rehire Inter-Campus Transfer Change in Job or Appointed Work Hours
3. DEPENDENTS Starting with yourself, list each dependent and enter his or her personal details. Check the box for each
benefit that your dependents will be enrolled in. You may only enroll family members into plans in which you are enrolled in. If
you have more than five dependents, you may complete a second form and fill out sections 1, 3, & 6. The Affordable Care Act
(ACA) requires employers to make reasonable efforts to obtain Social Security numbers for employees, spouses/domestic
partners, and dependents.
Nam e
(Last, First, Middle Initial)
Bir th Date
(m/d/yyyy)
Gender
( M/F)
Relationship
Code
1
Employee
Tax
2
Depe ndent?
(Yes/No)
Spouse/Dom
Partner Tax
2
Dependent?
(Yes/No)
Social Security
Number
Medical
Vision
Legal
Listed in Section 1
Self
1
Relationship Codes: S=Spouse R=Registered Domestic Partner N=Not Registered Domestic Partner C= Child (biological or adopted)
P=Step Child G=Grandchild W=Legal Ward K=Domestic Partner’s child
3
or grandchild O= Overage Disabled Child
4
2
Dependent eligibility requirements may be found in the “Eligible Family Members” section of the Complete Guide to Your UC Health Benefits.
3
If your domestic partnership is registered and you are the child’s stepparent under state law, enter Code “P” for Stepchild. Otherwise, enter code “K”.
4
Must be a tax dependent of employee or spouse/domestic partner unless SSI exception applies.
4. TAX SAVINGS ON INSURANCE PREMIUMS (TIP)
Your medical premium deductions will automatically occur on a pre-tax basis. If you wish to decline and have post-tax
deductions instead, check the below box and place your initials next to it. To learn more, you may go to the
TIP summary
plan description.
Decline/Opt Out of TIP Initials
Revised: 12/6/2018
Page 1 of 8
5. BENEFIT ELECTIONS Select your benefits by checking the box for the appropriate plan. If you leave a plan section
blank it is the same as declining and you will not be enrolled in that plan. Therefore, you MUST re-affirm your enrollment
in EACH plan or it will be assumed that you are declining your option to enroll.
MEDICAL PLAN
HMO Plans: or Decline Plan
Kaiser Permanente
Health Net Blue & Gold HMO
PPO Plans:
or
UC Care
Core
UC Health Savings Plan
Western Health Advantage
(WHA)
5
HMO plans require you live within the plan’s service area.
1.
2.
3.
4.
5.
EMPLOYEE & DEPENDENT PPG/PCP ID#: If enrolling in Health Net or
Western Health Advantage, please provide the
10-digit Primary Physician Group (PPG) or Primary Care Physician (PCP) ID number to avoid manual auto-assignment. Also,
list PCP ID number for all dependents if it is different from yours.
Dependent 1 PPG/PCP 10-digit ID#
Check if current Physician
Dependent 2 PPG/PCP 10-digit ID#
Check if current Physician
Dependent 3 PPG/PCP 10-digit ID#
Check if current Physician
Dependent 4 PPG/PCP 10-digit ID#
Check if current Physician
Dependent 5 PPG/PCP 10-digit ID#
Check if current Physician
Check if current Physician
Employee PPG/PCP 10-digit ID#
Check if same PPG/PCP for all dependents
Last Name
________________
________________
________________
________________
________________
________________
HEALTH BENEFITS ENROLLMENT FORM FOR NEWLY
ELIGIBLE EMPLOYEES
To enroll in the below plans, check one of the coverage levels listed for each plan:
SUPPLEMENTAL LIFE INSURANCE
DENTAL PLAN
Employee Only
Employee and Spouse /
Domes
tic Partner
Employee and Children)
Family
Also check a coverage amount below:
$10,000
$100,000
$20,000
$125,000
$30,000
$150,000
$40,000
$175,000
$50,000
$200,000
$60,000
$300,000
$70,000
$400,000
$80,000
$500,000
$90,000
The most important reason you choose to purchase life insurance is to protect your family financially in the event of your
death. To that end, it is critic
al that you have established the correct beneficiary designation. The most important consideration
is to make sure that the employee’s wishes are fulfilled upon the insured’s death and that legal complications are avoided. To
name your beneficiaries log in to At Your Service (AYS) Online.
DEPENDENT LIFE INSURANCE
FLEXIBLE SPENDING ACCOUNTS (FSA)
Basic Plan
or
Expanded Dependent Life
Spouse/Domestic Partner
Child(ren) Only
Family
Short-Term Disability (VSTD)
Long-Term Disability (VLTD)
Both VSTD and VLTD
Decline Plan
University of California does not participate in
California State Disability Insurance, although
employees who have worked at UC for less than
18 months may have some residual SDI benefits.
If you elect the medical UC Health Savings
Plan you are not eligible to participate in
the Health FSA. The effective date for
enrollment is the first of the month
following your enrollment, subject to pay
roll
deadlines.
Contribution:
Annual
DepCare FSA
Annual
The minimum annual contribution is
$180.00 and the maximum is set
according to IRS Guidelines. If you enroll
mid-year, your annual contribution will be
divided among the number of pay periods
left in the year. For more information,
please reference the Complete Guide to
Your Health Benefits.
6. AUTHORIZATION AND SIGNATURE My signature below indicates I have read and understand t he “Terms and Conditions” on
this form as well as the eligibility requirements of the benefit plans in which I have enrolled. I declare under penalty of perjury that all of
the above information is true to t he best of my knowledge.
I understand that if I left a plan section blank, it is the same as waiving and I
will not be enrolled in that plan. I agree it is my responsibility to c heck my earnings statements to veri fy my current benefits
enrollments and deductions.
Employee Signature
Date
Page 2 of 8
LEGAL PLAN
VOLUNTARY DISABILITY INSURANCE
ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)
Decline Plan
VISION PLAN
Vision Service Plan (VSP) Decline Plan
HEALTH SAVINGS ACCOUNT
You are only eligible for HSA if you elect the medical UC
Health Savings Plan.
HSA
Annual
For further information regarding IRS Regulations on maximum
contribution, refer to Complete Guide to Your UC Health Benefits.
ARAG Legal Plan
Decline Plan
Legal Plan is not offered during every Open Enrollment period
Flat Amount $20,000
1X Annual Salary
2X Annual Salary
3X Annual Salary
4X Annual Salary
Decline Plan
Employee: ______________
Dependent 1: ___________
Dependent 2: ___________
Dependent 3: __________
Dependent 4: __________
Dependent 5: __________
Delta Dental PPO
DeltaCare® USA DHMO
If enrolling in DeltaCare® DHMO, please provide the 6-digit PCD ID number to
avoid manual auto-assignment:
Check box if PCD is the same for all
dependents
Decline Plan
Decline Plan
Phone Number
Email Address
The retention schedule for this form can be found at http://recordsretention.ucop.edu/
Revised: 12/6/2018
Contribution:
Health FSA
Contribution:
Save Form
Print Form
Participation Terms and Conditions
Your Social Security number, and that of your
enrolled family members, is required for purposes
of benefit plan administration, for financial
reporting, to verify your identity,and for legally
required reporting purposes all in compliance with
federal and state laws.
If you are are confirmed as eligible for participation in
UC-sponsored plans, you are subject to the following
terms and conditions:
1.
With the exception of benefits provided or
administered by Anthem Blue Cross and UC-
sponsored medical plans require resolution of
disputes through arbitration. With regard to each
plan IT IS UNDERSTOOD THAT ANY DISPUTE
AS TO MEDICAL MALPRACTICE – THAT IS, AS
TO WHETHER ANY MEDICAL SERVICES
RENDERED UNDER THE CONTRACT WERE
UNNECESSARY OR UNAUTHORIZED OR
WERE IMPROPERLY, NEGLIGENTLY OR
INCOMPETENTLY RENDERED – WILL BE
DETERMINED BY SUBMISSION TO
ARBITRATION AS PROVIDED BY CALIFORNIA
LAW AND NOT BY A LAWSUIT OR RESORT TO
COURT PROCESS, EXCEPT AS CALIFORNIA
LAW PROVIDES FOR JUDICIAL REVIEW OF
ARBITRATION PROCEEDINGS. BOTH PARTIES
TO THE CONTRACT, BY ENTERING INTO IT,
ARE GIVING UP THEIR CONSTITUTIONAL
RIGHT TO HAVE ANY SUCH DISPUTE
DECIDED IN A COURT OF LAW BEFORE A
JURY AND INSTEAD ARE ACCEPTING THE
USE OF ARBITRATION. For more information
about each plan's arbitration provision please see
the appropriate plan booklet or call the plan.
2. UC and UC health and welfare plan vendors comply
with federal/state regulations related to the privacy of
personal/confidential information including the Health
Insurance Portability and Accountability Act of 1996
(HIPAA) as applicable. To fulfill their contracted
responsibilities and services health plans and
associated service vendors may share UC member
health information between and among each other
within the limits established by HIPAA and federal/state
regulations for purposes of health care operations,
payment, and treatment. A member's requested
restriction on the sharing of specified protected health
information for health care operations, payment, and
treatment will be honored as required by HIPAA.
3. By making an election with your written or electronic
signature you are authorizing the University to take
deductions from your earnings
(employees)/monthly Retirement Plan income (retirees)
to cover your contributions toward the monthly costs (if
any) for the plans you have chosen for yourself and
your eligible family members. You are also authorizing
UC to transmit your enrollment demographic data to the
plans in which you are enrolled.
4. You are subject to all terms and conditions of the UC-
sponsored plans in which you are enolledas stated in
the plan booklets and the University of California Group
Insurance Regulations.
5. By enrolling individuals as your family members you are
certifying that those individuals are eligible for coverage
based on the definitions and rules specified in the
University of California Group Insurance Regulations and
described in UC health and welfare plan eligibility
publications. You are also certifying under penalty of
perjury that all the information you provide regarding the
individuals you enroll is true to the best of your
knowledge.
6. If you enroll individuals as your family members you must
provide, upon request, documentation verifying that
those individuals are eligible for coverage. The carrier
may also require documentation verifying eligibility.
Verification documentation includes, but is not limited to,
marriage or birth certificates, domestic partner
verification, adoption papers, tax records and the like.
7. If your enrolled family member loses eligibility for UC-
sponsored coverage (for example because of divorce or
loss of eligible child status) you must notify UC by de-
enrolling that individual. If you wish to make a permitted
change in your health or flexible spending account
coverage you must notify UC within 31 days of the
eligibility loss event; for purposes of COBRA, eligibility
notice must be provided to UC within 60 days of the
family member's loss of coverage. However, regardless
of the timing of notice to UC, coverage for the ineligible
family member will end on the last day of the month in
which the eligibility loss event occurs (subject to any
continued coverage option available and elected.)
8. Making false statements about satisfying eligibility
criteria, failing to timely notify the University of a
family member's loss of eligibility, or failing to provide
verification documentation when requested may lead
to de-enrollment of the affected family members.
Employees/retirees may also be subject to
disciplinary action and de-enrollment from health
benefits and may be responsible for any UC-paid
premiums due to misuse of plan.
9. Under current state and federal tax laws, the value of
the contribution UC makes toward the cost of health
coverage provided to domestic partners and certain
other family members who are not "your dependents"
under state and federal tax rules may be considered
imputed income that will be subject to income taxes,
FICA (Social Security and Medicare), and any other
required payroll taxes. (Coverage provided to California
registered domestic partners is not subject to imputed
income for California state tax purposes.)
Revised: 12/6/2018
Page 3 of 8
10. If you specifically ask UC representatives to intercede
on your behalf with your insurance plan, University
representatives will request the minimum necessary
protected health information required to assist you with
your problem. If more protected health information is
needed to solve your problem in compliance with state
laws and federal privacy laws (including HIPAA), you
may be required to sign an authorization allowing UC to
provide the health plan with relevant protected health
information or authorizing the health plan to release
such information to the University representative.
11. Actions you take during Open Enrollment will be effective
the following January 1unless otherwise stated
- provided
all electronic and form transactions have been completed
properly and submitted timely.
IMPORTANT NOTICES
HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT OF 1996 (HIPAA)
NOTIFICATION FOR MEDICAL PROGRAM
ELIGIBILITY
If you are declining enrollment for yourself or your eligible
family members because of other medical insurance or
group medical plan coverage, you may be able to enroll
yourself and your eligible family members* in a UC-
sponsored medical plan if you or your family members lose
eligibility for that other coverage (or if the employer stops
contributing toward the other coverage for you or your family
members.) You must request enrollment within 31 days after
you or your family member's other medical coverage ends
(or after the employer stops contributing toward the other
coverage).
In addition, if you have a newly eligible family member as a
result of marriage or domestic partnership, birth, adoption, or
placement for adoption, you may be eligible to enroll your
newly eligible family member. If you are an employee you
may be eligible to enroll yourself, in addition to your eligible
family member(s). You must request enrollment within 31
days after the marriage or partnership, birth, adoption, or
placement for adoption.
If you decline enrollment for yourself or for an eligible family
member because of coverage under Medicaid (in California,
Medi-Cal) or under a state children's health insurance
program (CHIP) you may be able to enroll yourself and your
eligible family members in a UC-sponsored plan if you or your
family members lose eligibility for that coverage. You must
request enrollment within 60 days after your coverage or your
family members' coverage ends under Medicaid or CHIP.
Also, if you are eligible for health coverage from UC but
cannot afford the premiums, some states have premium
assistance programs that can help pay for coverage. For
details, contact the U.S. Department of Health and Human
Services, Centers for Medicare and Medicaid Services at
www.cms.gov or 1-877-267-2323 ext. 61565.
IF YOU DO NOT ENROLL YOURSELF AND/OR YOUR
FAMILY MEMBER(S) IN MEDICAL COVERAGE WITHIN
THE 31 DAYS WHEN FIRST ELIGIBLE, WITHIN A
SPECIAL ENROLLMENT PERIOD DESCRIBED ABOVE,
OR WITHIN AN OPEN ENROLLMENT PERIOD, YOU MAY
BE ELIGIBLE TO ENROLL AT A LATER DATE. However,
even if eligible, each affected individual will need to complete
a waiting period of 90 consecutive calendar days before
medical coverage becomes effective and employee
premiums may need to be paid on an after-tax basis (retiree
premiums are always paid after-tax). Otherwise, you/they
can enroll during the next Open Enrollment Period.
To request special enrollment or obtain more information,
employees should contact their local Benefits Office and
retirees should call the UC Retirement Administration
Service Center (1-800-888-8267).
Note: If you are enrolled in a UC medical plan you may be able
to change medical plans if:
- you acquire a newly eligible family member; or
- your eligible family member loses other coverage.
In either case you must request enrollment within 31 days of
the occurrence.
* To be eligible for plan membership, you and your family
members must meet all UC employee or retiree enrollment
and eligibility require-ments. As a condition of coverage,
all plan members are subject to eligibility verification by
the university and/or insurance carriers, as described in
the participation terms and conditions.
By authority of the Regents, University of California Human
Resources located in Oakland administers all benefit plans in
accordance with applicable plan documents and regulations,
custodial agreements, University of California Group
Insurance Regulations, group insurance contracts, and state
and federal laws. No person is authorized to provide benefits
information not contained in these source documents and
information not contained in these source documents cannot
be relied upon as having been authorized by the Regents.
Source documents are available for inspection upon request
(1-800-888-8267). What is written here does not constitute a
guarantee of plan coverage or benefits--particular rules and
eligibility requirements must be met before benefits can be
received.
The University of California intends to continue the benefits
described here indefinitely; however the benefits of all
employees, retirees, and plan beneficiaries are subject to
change or termination at the time of contract renewal or at
any other time by the University or other governing
authorities. The University also reserves the right to determine
new premiums, employer contributions, and monthly costs at
any time. Health and welfare benefits are not accrued or
vested benefit entitlements. UC's contribution toward the
monthly cost of the coverage is determined by UC and may
change or stop altogether and may be affected by the state of
California's annual budget appropriation. If you belong to an
exclusively represented bargaining unit some of your benefits
Revised: 12/6/2018
Page 4 of 8
may differ from the ones described here. For more
information employees should contact their Human
Resources Office and retirees should call the UC
Retirement Administration Service Center
(1-800-888-8267).
In conformance with applicable law and University policy, the
University is an affirmative action/equal opportunity employer.
Please send inquiries regarding the University's affirmative
action and equal opportunity policies for staff to System wide
AA/EEO Policy Coordinator, University of California Office of
the President, 1111 Franklin Street, 5th Floor, Oakland CA
94607 and for faculty to the Office of Academic Personnel,
University of
California Office of the President, 1111 Franklin
Street, Oakland CA 94607.
UNIVERSITY OF CALIFORNIA HEALTH
CARE PLAN NOTICE OF PRIVACY
PRACTICES - SELF-FUNDED 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.
The University offers various healthcare options to its
employees and retirees and their eligible family members
through the UC Healthcare Plan. Several options are self-
funded group health plans for which the University acts as its
own insurer and directly pays the claims. This notice
describes the privacy practices that the University has
established for these options which are referred to as the
"Self-Funded Plans." They are managed for the University by
business associates, which are third party administrators that
interact with the healthcare providers and handle members'
claims.
The other healthcare options offered under the UC
Healthcare Plan are fully insured group health plans for which
the insurance company or health maintenance organization
(HMO) assumes the financial risk of paying for the plan
benefits. The notices of privacy practices for those plans are
available directly from the insurance carrier or HMO. Please
go to http://ucnet.universityofcalifornia.edu/compensation-
and-benefits/ for a current list of options.
UC'S Commitment
The University is committed to protecting the privacy of your
protected health information or PHI. PHI refers to health
information that a Self-Funded Plan creates or receives that
relates to your physical or mental health, your healthcare, or
payment for your healthcare. In most cases, your PHI is
maintained by the business associate that serves as the third
party administrator for the Self-Funded Plan in which you
participate, but the University may also hold health-related
information. Generally, the University-held information is
limited to enrollment data, but in limited instances, it may
include information you provide to designated UC staff to help
with coordination of benefits, or resolving complaints.
The privacy protections described in this notice reflect the
requirements of federal regulations issued under the
Health Insurance Portability and Accountability Act (HIPAA).
They require the Self-Funded Plans to:
- Comply with HIPAA privacy standards and other federal
laws;
- Make sure that your PHI is protected;
- Give you this notice of the Self-Funded Plans' legal duties
and privacy practices with respect to your PHI; and
- Follow the terms of the notice that is currently in effect.
How the Self-Funded Plans Will Use and
Disclose Protected Health Information
About You
The following sections describe different ways that a
Self-Funded Plan might use and disclose your PHI. Not
every use or disclosure will be listed. All of the ways that
a Self-Funded Plan is permitted to use and disclose PHI,
however, will fall within one of the categories. Use and
disclosure of some PHI, such as certain drug and
alcohol information, HIV information, and mental health
information, is further restricted.
- Treatment. A Self-Funded Plan may use and disclose your
PHI to doctors, nurses, technicians, and other personnel who
are involved in providing you with medical treatment or
services. For example, a doctor treating you for a broken leg
may need to know if you have diabetes because diabetes
may slow the healing process. The doctor may then tell the
dietitian if you have diabetes so the dietitian can meet any
special menu needs. Different departments may share your
PHI so they can coordinate services you need, such as lab
work, x-rays, and prescriptions.
- Payment. A Self-Funded Plan may use and disclose your
PHI in the course of activities that involve reimbursement
for healthcare, such as determination of eligibility for
coverage, claims processing, billing, obtaining, and
payment of premium, utilization review, medical necessity
determinations, and pre-certifications.
- Healthcare Operations for a Self-Funded Plan. Self-
Funded Plans may use and disclose your PHI to carry out
business operations and to assure that all enrollees receive
quality care. For example, a Self-Funded Plan may disclose
your PHI to a business associate who handles claims
processing or administration, data analysis, utilization review,
quality assurance, benefit management, practice
management or referrals to specialists, or provides legal,
actuarial, accounting, consulting, data aggregation,
management, or financial services.
- Healthcare Operations for the UC Healthcare Plan. The
University may also engage a business associate to carry
out healthcare operations on behalf of the entire UC
Healthcare Plan in its role as an organized healthcare
arrangement of a single plan sponsor under HIPAA. The
group health plans participating in the University's organized
healthcare arrangement as of the date of this notice include
UC Care, UC Shield Health Savings Plan, OptumRx, Health
Net Blue & Gold, Kaiser Permanente, Western Health
Advantage, Core, High Option Supplement to Medicare,
Revised: 12/6/2018
Page 5 of 8
Anthem Blue Cross Medicare PPO, Anthem Blue Cross
Medicare PPO without RX, Health Net Seniority Plus,
Kaiser Permanente Senior Advantage, UC Medicare
Coordinator Program Health Reimbursement Account,
Post-Deductible Health Reimbursement Account, Stand
Alone Health Reimbursement Account, Delta Dental,
Delta Care USA Plan, and VSP. You can find a current
list of options at http://ucnet.universityofcalifornia.edu/
compensation-and-benefits/.
- Plan Sponsor. A Self-Funded Plan may disclose summary
health information (that is claims data that is stripped of most
individual identifiers) to the University in its role as plan
sponsor in order to obtain bids for health insurance coverage
or to facilitate, modifying, amending, or terminating a plan. A
Self-Funded Plan may also provide the University enrollment
or disenrollment information. In addition, if you request help
from the University in coordinating your benefits or resolving
a complaint, a Self-Funded Plan may disclose your PHI to
designated University staff, but no PHI may be disclosed to
facilitate employment-related actions or decisions or for
matters involving other benefits or benefit plan. The
University may not further disclose any PHI that is disclosed
to it in these limited instances.
- As Required By Law. A Self-Funded Plan will disclose
your PHI if required to do so by federal, state, or local law,
or regulation.
- To Avert a Serious Threat to Health or Safety. A Self-
Funded Plan may disclose your PHI when necessary to
prevent or lessen a serious threat to your health and safety
or the health and safety of the public or another person.
Any disclosure, however, would only be to someone able to
help prevent the threat.
- Military and Veterans. If you are or were a member of the
armed forces, a Self-Funded Plan may release your PHI to
military command authorities as authorized or required by
law. A Self-Funded Plan may also release medical
information about foreign military personnel to the
appropriate military authority as authorized or required by
law.
- Research. In limited circumstances, a Self-Funded Plan
may use and disclose PHI for research purposes, subject to
the confidentiality provisions of state and federal law. Your
PHI may be important to further research efforts and the
development of new knowledge. All research projects
conducted by the University of California must be approved
through a special review process to protect member safety
welfare and confidentiality.
- Workers' Compensation. A Self-Funded Plan may release
PHI for workers' compensation or similar programs as
permitted or required by law. These programs provide
benefits for work-related injuries or illness.
- Health Oversight Activities. A Self-Funded Plan may
disclose PHI to governmental, licensing, auditing, and
accrediting agencies as authorized or required by law.
- Legal Proceedings. A Self-Funded Plan may disclose PHI
to courts, attorneys, and court employees in the course of
conservatorship and certain other judicial or administrative
proceedings.
- Lawsuits and Disputes. If you are involved in a
lawsuit or other legal proceeding, a Self-Funded Plan
may disclose your PHI in response to a court or
administrative order, or in response to a subpoena,
discovery request, warrant, summons, or other lawful
process.
- Law Enforcement. If authorized or required by law, a
Self-Funded Plan may disclose your PHI under limited
circumstances to a law enforcement official in response to
a warrant or similar process, to identify or locate a
suspect, or to provide information about the victim of a
crime.
- National Security and Intelligence Activities. If
authorized or required by law, a Self-Funded Plan may
release your PHI to authorized federal officials for
intelligence, counterintelligence, and other national security
activities.
- Protective Services for the United States President
and Others. A Self-Funded Plan may disclose your PHI
to authorized federal and state officials so they may
provide protection to the President, other authorized
persons, or foreign heads of state, or conduct special
investigations as authorized or required by law.
- Inmates. If you are an inmate of a correctional institution or
under the custody of a law enforcement official, a Self-
Funded Plan may release your PHI to the correctional
institution or law enforcement official, as authorized or
required by law. This release would be necessary for the
institution to provide you with healthcare; to protect your
health and safety or the health and safety of others; or for the
safety and security of the correctional institution.
Required Disclosures
A Self-Funded Plan may be required to disclose your PHI to
the Department of Health and Human Services if the Secretary
is conducting a compliance audit.
Your Rights
You have the following rights regarding the PHI that a Self-
Funded Plan maintains about you:
- Right to Inspect and Copy. With certain exceptions you
have the right to inspect and obtain a copy of your PHI that is
maintained by or for a Self-Funded Plan. To inspect and
obtain a copy of the PHI you must submit your request in
writing to the UC Healthcare Plan Privacy Office, 300
Lakeside Drive, 6th Floor, Oakland, CA
94612, Attention: HIPAA Privacy Officer. You may be
charged a fee for the costs of copying mailing or other
supplies associated with your request.
Revised: 12/6/2018
Page 6 of 8
A Self-Funded Plan may deny your request to inspect and/or
obtain a copy in certain limited circumstances. For example,
HIPAA does not permit you to access or obtain copies of
psychotherapy notes. If your request is denied, you will be
informed in writing, and you may request that the denial be
reviewed. The person conducting the review will not be the
person who denied your request. The plan will comply with
the outcome of the review.
- Right to Request an Amendment. If you believe that the
PHI maintained by a Self-Funded Plan is incorrect or
incomplete, you may request that the plan amend the
information. You have the right to request an amendment for
as long as the information is kept by or for the plan. A
request for an amendment should be made in writing and
submitted to the UC Healthcare Plan Privacy Office, 300
Lakeside Drive, 6th Floor, Oakland, CA 94612, Attention:
HIPAA Privacy Officer. In addition, you must provide a
reason that supports your request.
A Self-Funded Plan may deny your request for an
amendment if it is not in writing or does not include a
reason to support the request. In addition, the plan may
deny your request if you ask to amend information that was
not created by the plan; is not part of the PHI maintained
by or for the plan; is not part of the information that you
would be permitted to inspect and copy under the law; or if
the information is accurate and complete. If the request is
granted, the plan will forward your request to other entities
that you identify that you want to receive the corrected
information. For example, if your PHI has been disclosed to
the UC staff so that it may help to coordinate benefits or
resolve a complaint, you may direct the plan to share the
correction with the designated staff members.
- Right to an Accounting of Disclosures. You have the
right to receive an "accounting of disclosures", which is a list
of disclosures such as those that were made of PHI about
you, with the exception of certain documents, including those
relating to treatment, payment, and healthcare operations
and disclosures made to you or consistent with your
authorization. To request an accounting of disclosures, you
must submit your request in writing to the UC Healthcare
Plan Privacy Office, 300 Lakeside Drive, 6th Floor, Oakland,
CA 94612, Attention: HIPAA Privacy Officer.
Your request must state a time period which may not be
longer than six years and may not include dates before
April 14, 2003.
Your request should indicate in what form you want the list
(for example, on paper or electronically). The first list you
request within a 12-month period will be free. For additional
lists, the plan may charge you for the costs of providing the
list. You will be notified of any costs involved and you may
choose to withdraw or modify your request at that time
before any costs are incurred.
- Right to Request Restrictions. You have the right to
request a restriction or limitation on the use and disclosure
of your PHI for treatment, payment or healthcare
operations, or to request a restriction on the PHI that the
plan may disclose about you to someone who is involved in
your care, or the payment for your care such as a family
member or friend. The plan is not required to agree to your
request. If the plan agrees to your request, it will comply
with the requested restriction unless the information is
needed to provide you emergency treatment or to assist in
disaster relief efforts.
To request a restriction you must submit your request in writing
to the UC Healthcare Plan Privacy Office, 300
Lakeside Drive, 6th Floor, Oakland, CA 94612, Attention:
HIPAA Privacy Officer. Your request should state the
information you want to limit; whether you want to limit the
plan's use disclosure or both; and to whom you want the
limits to apply for example disclosures to your spouse.
- Right to Request Confidential Communications. You
have the right to request that a Self-Funded Plan
communicate with you about medical matters in a certain way
or at a certain location. For example, you can ask that the
plan only contact you at work or by mail to a specific address.
To request confidential communications, you must submit
your request in writing to the UC Healthcare Plan Privacy
Office, 300 Lakeside Drive, 6th Floor, Oakland, CA 94612,
Attention: HIPAA Privacy Officer. The plan will accommodate
all reasonable requests and will not ask you the reason for
your request. Your request must specify how or where you
wish to be contacted.
- Right to a Paper Copy of This Notice. You may ask
the University to give you a copy of this notice at any
time. Even if you have agreed to receive this notice
electronically, you are still entitled to a paper copy of
this notice. To obtain a paper copy of this notice, contact
the UC Healthcare Plan Privacy Office, 300 Lakeside
Drive, 6th Floor, Oakland, CA 94612.
- Other Uses of Medical Information. Other uses and
disclosures of PHI not covered by this notice will be made
only with your written permission. This includes most uses
and disclosures of psychotherapy notes uses and disclosures
of PHI for marketing purposes, and uses and disclosures of
PHI that constitute a sale of PHI. If you provide us permission
to use or disclose your PHI, you may revoke that permission,
in writing, at any time. If you revoke your permission, the plan
will no longer use or disclose your PHI for the reasons stated
in your written authorization. Please understand that the plan
cannot take back any disclosures already made with your
permission.
- Breach. You have the right to be notified of the discovery of
a breach of unsecured PHI.
- Genetic Information is Protected Health Information.
In accordance with the Genetic Information
Nondiscrimination Act (GINA), a Self-Funded Plan will not
use or disclose genetic information for underwriting
purposes, which includes eligibility determinations,
premium computations, applications of any pre-existing
condition exclusions, and any other activities related to the
creation, renewal, or replacement of a contract of health
insurance or health benefits.
Revised: 12/6/2018
Page 7 of 8
Changes to This Notice
The Self-Funded Plans reserve the right to change this notice
and to make the revised or changed notice effective for PHI
your plan already maintains on you as well as any
information the plan receives or creates in the future.
A copy of the current notice will be posted at the UC
website at
http://ucnet.universityofcalifornia.edu/forms/pdf/uc-
healthcare-plan-notice-of-privacy-practices-self-funded-
plans.pdf. The notice will contain the effective date on
the first page in the top right-hand corner. In addition, a
copy of the notice that is currently in effect will be given
to new health plan members and thereafter, available
upon request.
Complaints
If you believe your privacy rights have been violated, you may
file a complaint with your Self-Funded Plan, or with the
Secretary of the Department of Health and Human Services.
To file a complaint on your Self-Funded Plan, contact UC
Healthcare Plan Privacy Office, 300 Lakeside Drive, 6th Floor,
Oakland, CA 94612, Attention: HIPAA Privacy Officer. Email
will not be accepted; all complaints must be submitted in
writing.
You will not be retaliated against for filing a complaint.
Questions
If you have questions or for further information regarding this privacy
notice, contact the UC Healthcare Plan
HIPAA Privacy Officer at 1-800-888-8267, press 2 or 510-287-3857
Revised: 12/6/2018
Page 8 of 8
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Newly-eligible-employees FR.008 - Health Benefits Enrollment Form For Newly Eligible Employees

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Completed 18 July 2020

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