Page 30 - Confie Benefits Guide 01-18_FINAL_r2_dp wording.pub

Important No ces (con nued)

Plan Sponsor: The Company is the Plan Sponsor and Plan Administrator.
No ce of Privacy Prac ces The Plan may disclose to the Company, in summary form, claims history
and other informa on so that the Company may solicit premium bids for

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY health benefits, or to modify, amend or terminate the Plan. This summary
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS IN‐ informa on omits your name and Social Security Number and certain
FORMATION. PLEASE REVIEW IT CAREFULLY. other iden fying informa on. The Plan may also disclose informa on
about your par cipa on and enrollment status in the Plan to the Compa‐
The effec ve date of this No ce of Confie Seguros Holdings II Co. Health ny and receive similar informa on from the Company. If the Company
Informa on Privacy Prac ces (the “No ce”) is January 1, 2018. Anthem agrees in wri ng that it will protect the informa on against inappropriate
Blue cross (the “Plan”) provides health benefits to eligible employees of use or disclosure, the Plan also may disclose to the Company a limited
Confie Seguros Holdings II Co. (the “Company”) and their eligible depend‐ data set that includes your PHI, but omits certain direct iden fiers, as
ents as described in the summary plan descrip on(s) for the Plan. The described later in this No ce.
Plan creates, receives, uses, maintains and discloses health informa on
about par cipa ng employees and dependents in the course of providing The Plan may disclose your PHI to the Company for plan administra on
these health benefits. func ons performed by the Company on behalf of the Plan, if the Compa‐
ny cer fies to the Plan that it will protect your PHI against inappropriate
For ease of reference, in the remainder of this No ce, the words “you,” use and disclosure.
“your,” and “yours” refers to any individual with respect to whom the
Example: The Company reviews and decides appeals of claim denials
Plan receives, creates or maintains Protected Health Informa on, includ‐
under the Plan. The Claims Administrator provides PHI regarding an ap‐
ing employees and COBRA qualified beneficiaries, if any, and their respec‐
pealed claim to the Company for that review, and the Company uses PHI
ve dependents.
to make the decision on appeal.
The Plan is required by law to take reasonable steps to protect your Pro‐
Business Associates: The Plan and the Company hire third par es, such as
tected Health Informa on from inappropriate use or disclosure.
a third party administrator (the “Claims Administrator”), to help the Plan
Your “Protected Health Informa on” (PHI) is informa on about your past, provide health benefits. These third par es are known as the Plan’s
present, or future physical or mental health condi on, the provision of “Business Associates.” The Plan may disclose your PHI to Business Associ‐
health care to you, or the past, present, or future payment for health care ates, like the Claims Administrator, who are hired by the Plan or the Com‐
provided to you, but only if the informa on iden fies you or there is a pany to assist or carry out the terms of the Plan. In addi on, these Busi‐
reasonable basis to believe that the informa on could be used to iden fy ness Associates may receive PHI from third par es or create PHI about
you. Protected health informa on includes informa on of a person living you in the course of carrying out the terms of the Plan. The Plan and the
or deceased (for a period of fi y years a er the death.) Company must require all Business Associates to agree in wri ng that
they will protect your PHI against inappropriate use or disclosure, and will
The Plan is required by law to provide no ce to you of the Plan’s du es
require their subcontractors and agents to do so, too.
and privacy prac ces with respect to your PHI, and is doing so through
this No ce. This No ce describes the different ways in which the Plan For purposes of this No ce, all ac ons of the Company and the Business
uses and discloses PHI. It is not feasible in this No ce to describe in detail Associates that are taken on behalf of the Plan are considered ac ons of
all of the specific uses and disclosures the Plan may make of PHI, so this the Plan. For example, health informa on maintained in the files of the
No ce describes all of the categories of uses and disclosures of PHI that Claims Administrator is considered maintained by the Plan. So, when this
the Plan may make and, for most of those categories, gives examples of No ce refers to the Plan taking various ac ons with respect to health
those uses and disclosures. informa on, those ac ons may be taken by the Company or a Business
Associate on behalf of the Plan.
The Plan is required to abide by the terms of this No ce un l it is re‐
placed. The Plan may change its privacy prac ces at any me and, if any How the Plan May Use or Disclose Your PHI
such change requires a change to the terms of this No ce, the Plan will
revise and re‐distribute this No ce according to the Plan’s distribu on The Plan may use and disclose your PHI for the following purposes with‐
process. Accordingly, the Plan can change the terms of this No ce at any out obtaining your authoriza on. And, with only limited excep ons, we
me. The Plan has the right to make any such change effec ve for all of will send all mail to you, the employee. This includes mail rela ng to your
your PHI that the Plan creates, receives or maintains, even if the Plan spouse and other family members who are covered under the Plan. If a
received or created that PHI before the effec ve date of the change. person covered under the Plan has requested Restric ons or Confiden al
Communica ons, and if the Plan has agreed to the request, the Plan will
The Plan is distribu ng this No ce, and will distribute any revisions, only send mail as provided by the request for Restric ons or Confiden al Com‐
to par cipa ng employees and COBRA qualified beneficiaries, if any. If munica ons.
you have coverage under the Plan as a dependent of an employee, or
COBRA qualified beneficiary, you can get a copy of the No ce by re‐ Your Health Care Treatment: The Plan may disclose your PHI for treat‐
ques ng it from the contact named at the end of this No ce. ment (as defined in applicable federal rules) ac vi es of a health care
provider.
Please note that this No ce applies only to your PHI that the Plan main‐
tains. It does not affect your doctor’s or other health care provider’s pri‐ Example: If your doctor requested informa on from the Plan about previ‐
vacy prac ces with respect to your PHI that they maintain. ous claims under the Plan to assist in trea ng you, the Plan could disclose
your PHI for that purpose.

Example: The Plan might disclose informa on about your prior prescrip‐
Receipt of Your PHI by the Company and Business Associates ons to a pharmacist for the pharmacist’s reference in determining
whether a new prescrip on may be harmful to you.
The Plan may disclose your PHI to, and allow use and disclosure of your
PHI by, the Company and Business Associates without obtaining your
authoriza on.

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