This section contains important notices describing your rights under various federal laws affecting benefits. It also includes a glossary of benefit terms.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 provides protection for employees and dependents who have pre-existing medical conditions or might be denied health coverage based on factors related to an individual’s health. HIPAA includes changes that:
Under HIPAA, the employer may impose a pre-existing condition exclusion with respect to an employee, dependent, or beneficiary only if the following requirements are satisfied:
How Portability Affects City of Atlanta Employees
Effective January 1, 1998, you and your dependents do not have to satisfy a pre-existing condition waiting period if you provide certification of prior creditable coverage sufficient to satisfy the respective pre-existing condition waiting periods.
When an Employee Terminates Coverage
HIPAA requires that your insurance carrier provide you (and your dependents) with certificates of coverage automatically upon termination of coverage.
Special Enrollment Periods
There are special enrollment periods for you and your dependents who:
In addition there also are special enrollment periods for new dependents resulting from marriages, births, or adoptions. An unenrolled member may enroll within 31 days of such a special qualifying event.
All new hires should submit a copy of the HIPAA Form received from their previous employer to the DHR – Employee Benefits for proper credit.
COBRA Continuation Coverage
COBRA Continuation Coverage
Under the Consolidated Omnibus Reconciliation Act of 1985, Title X (COBRA), terminated employees and their eligible dependents may continue group health plan coverage. We urge you to read this description of the “continuation coverage” option carefully, and to make sure you and your spouse read and understand the rights and responsibilities in connection with this continuation of coverage.
If you are currently covered under The City of Atlanta Health Plan, you will be entitled to continue your and your family’s Health Plan coverage for up to 18 months from the date coverage would have terminated because of voluntary or involuntary termination. If a qualified beneficiary is deemed disabled for Social Security, at the date of the qualifying event, or within the first 60 days following the qualifying event, the continuation coverage period is 29 months for all the members of your family who have elected COBRA. The 18-month period also may be extended if other events (such as a death or divorce) occur during that 18-month period. Employees discharged because of “gross misconduct” would not be eligible for continuation of coverage. Dependents who no longer qualify as dependents under the City of Atlanta Health Plan are eligible to apply for continuation of coverage. If you should die or become divorced, and if your spouse and dependents are covered by the City of Atlanta Health Plan at that time, they will be entitled to continue health coverage for up to 36 months. Continuation coverage also is available for your children for up to 36 months. If an Eligible Person is 60 years old on the date COBRA continuation coverage started COBRA coverage may extend up to the time of Medicare eligibility. If you have a newborn child, adopt a child, or have a child placed in your home pending adoption (for whom you have financial responsibility), while your COBRA continuation is in effect, you may add this child to your coverage.
Continuation of coverage is optional on the part of the employee or dependent. Those who elect continuation of coverage will be required to pay 102% of the total monthly group premium for the applicable class of coverage. For the extended disability coverage, employees may be required to pay up to 150% of the monthly group premium for coverage during the 19th through the 29th month. Persons 60 years old on the date of COBRA eligibility may be required to pay up to 120% of the premium for extended time. There will be no contribution made by the City of Atlanta. Premiums are due monthly and in advance. You should note that your continuation coverage will stop if the premiums for this coverage are not paid on time. If you elect to continue coverage, new dependents may be added during the period of continuation on the same basis as they are added for active employees. If during continuation of coverage, health benefits and premium rates change, your coverage and costs will be affected accordingly. Should Open Enrollment occur during the period of your continuation, you will retain your right to switch to a different option.
When Coverage Ends
If you or covered members of your family become entitled to Medicare or are covered under another employer-sponsored health plan, which does not limit coverage due to preexisting conditions, the continuation coverage from the City of Atlanta Health Plan will cease. In addition, your coverage will cease if the City of Atlanta should terminate the Health Plan or you cease to pay premiums. Once the period of coverage continuation has expired, anyone receiving continuation coverage will be eligible to convert to individual policies, as provided under the City of Atlanta plan.
What You Must Do
You or your spouse or dependents must notify the DHR – Employee Benefits when your dependent child reaches the maximum age under the plan, or in the event you become divorced. It is important that you notify us of your or your dependents loss of plan eligibility promptly – in advance, if possible, but no later than 60 days from the date coverage would otherwise have terminated in order to be eligible to elect continuation coverage. Within 14 days after the end of the month in which you notified the DHR – Employee Benefits, you or your eligible dependents will be mailed information and forms regarding continuation of coverage. You or your dependent must return the completed election forms within 60 days. If continuation of coverage is selected within 60 days, you or your dependent will then have an additional 45 days to pay the applicable premium, retroactive to the date coverage would otherwise have terminated. If you would like further information on continuation coverage under the City of Atlanta Health Plan, please contact the DHR – Employee Benefits at (404) 330-6036.
When your group health insurance ends due to termination of employment with the City of Atlanta or due to expiration of COBRA continuation of health care coverage under the group contract you may apply for converted health coverage. For additional information contact the DHR – Employee Benefits (404) 330-6036.
If you terminate your employment with the City, or your COBRA eligibility terminates, A CERTIFICATE OF GROUP HEALTH PLAN COVERAGE will be mailed by your Insurance Carrier/ HMO, to the last address on their file.
If you are a new employee, have previously waived your health insurance, or are adding a dependent other than a newborn (or child placed in your home pending adoption), you should provide copies of the CERTIFICATE OF GROUP HEALTH PLAN COVERAGE issued to you or your dependents, by the previous employer(s) for CREDITABLE PRIOR COVERAGE.
Other Federal Notices
Other Federal Notices
Newborns’ and Mothers’ Health Protection Act
Under federal law group health plans may not restrict the hospital length of stay for a new mother or child to less than 48 hours for a normal delivery and 96 hours for Cesarean delivery, nor may they require that a provider obtain authorization in order to prescribe a length of stay not in excess of 48 or 96 hours. However, federal law generally does not prohibit the mother’s attending provider or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).
Women’s Health and Cancer Rights Act
In compliance with the Women’s Health and Cancer Rights Act of 1998, the Medical Plan provides coverage for the following medical conditions in conjunction with a mastectomy:
These services will be provided in a manner determined in consultation with the attending physician and the patient. Coverage is subject to applicable deductibles and coinsurance amounts that apply to other benefits under the plan.
HIPAA Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children’s health insurance program is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents’ coverage ends under Medicaid or a state children’s health insurance program.
If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children’s health insurance program with respect to coverage under this plan, you may be able to enroll yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’ determination of eligibility for such assistance.
To request special enrollment or obtain more information, contact the DHR – Employee Benefits at 404-330-6036.
Glossary of Important Terms
Glossary of Important Terms
Application: A signed statement of facts requested by the company on the basis of which the company decides whether or not to issue a policy. This then becomes part of the health insurance contract when the policy is issued.
Approved Amount: The amount determined by the Medicare carrier to be reasonable and fair for each service.
Beneficiary: The person designated or provided for by the terms to receive the proceeds upon the death of the insured.
Benefit Package: A collection of specific services or benefits that the HMO and Indemnity Plan is obligated to provide under terms of its contracts with subscriber groups or individuals.
Benefit Period: The period of time during which benefits are available, such as a year or for the lifetime of the contract.
Benefits: The amount payable by an insurance company for covered services.
Carrier: The insurance company responsible for processing claims; it may perform the carrier function on its own behalf, or for another entity who pays losses; under the Medicare program, for example, the Social Security Administration selects private insurance companies to administer Part B claims.
Claim: A demand to the insurer for the payment of benefits under the insurance contract.
Coinsurance: The fixed percentage of covered charges you must pay after any deductible has been subtracted. For example, if a plan pays 80 percent of covered charges (after applying any deductible), you would be responsible for the deductible and the 20 percent balance.
Consumer Choice Option (CCO): A health plan mandated in 1999 by the Georgia General Assembly. This plan allows members to nominate a non-network provider that will act as a part of the network. An employee who has selected the CCO may elect a qualified provider to render any covered services. Member is subject to normal rules and conditions that apply to a contracted network provider, i.e., reimbursement, usual customary and reasonable costs, and prescription drugs. Members will incur additional costs if they choose the CCO health plan.
Contingent Beneficiary: Person named to receive proceeds or benefits should an unforeseen event prevent the named Primary Beneficiary(ies) from collecting benefits (or insurance).
Conversion Privilege: A privilege granted in an insurance policy to convert to a different plan of insurance without providing evidence of insurability. The privilege granted by a group policy is to convert to an individual policy upon termination of group coverage.
Coordination of Benefits: Establishes procedures to be followed in the event of duplicate coverage thus assuring that no more than 100 percent of the costs of care are reimbursed to the patient.
Copayment: A fixed dollar amount you must pay for a service or benefit provided by a plan.
Coverage: The amount or extent to which any particular treatment or service is insured by a health provider.
Deductible: The amount of covered charges you must pay before the plan pays benefits, for example, calendar-year deductible and inpatient hospital deductible. Generally, no more than two or three family members must meet the calendar year deductible. However, some plans have a family calendar-year deductible, which can be met by any or all of those covered.
Dental Care: Coverage may include routine diagnostic and preventive services and one or more of the following treatment services: restorative, crown and bridge, endodontic, oral surgery, periodontal, prosthetic, and orthodontic. Some prepaid plans (DMOs) limit coverage to preventive services for children.
Disability: A limitation of physical or mental functional capacity resulting from sickness or injury. It may be partial or total. (See also Partial Disability and Total Disability.)
Domestic Partnership: A union in which two individuals (unrelated by blood) of the opposite or same sex choose to share their lives in a close and committed relationship of mutual caring; who live together and have signed a Declaration of Domestic Partnership in which they have agreed to be jointly responsible for basic living expenses incurred during the Domestic Partnership.
Effective Date: The date on which the insurance under a policy begins.
Eligibility Period: A specified length of time, frequently 30 days following the eligibility date during which an individual member of a particular group will remain eligible to apply for insurance under a group life or health insurance policy without evidence or insurability.
Eligible Date: The date on which an individual member of a specified group becomes eligible to apply for insurance under the (group life or health) insurance plan.
Eligible Employees: Those members of a group who have met the eligibility requirements under a group life or health insurance plan.
Evidence of Insurability: Any statement of proof of a person’s physical condition and/ or other factual information affecting his/her acceptance for insurance.
Exclusions: Charges, services, or supplies that are not covered. A plan does not provide or pay for excluded items, nor do charges for them apply toward deductibles and catastrophic limits.
Flexible Spending Account (FSA): A benefit option that reimburses employees for certain expenses they incur. Money is deducted from paychecks on a pre-tax basis. It most often covers reimbursements for medical expenses not covered under other insurance, or childcare expenses.
Grace Period: A specified period – 31 days – after a premium payment is due, in which the policyholder may make such payment, and during which the protection of the policy continues.
HCFA: Health Care Financing Administration. The agency of the U.S. Department of Health and Human Services that is responsible for administering the Medicare and Medicaid programs.
HIPAA: Health Insurance Portability and Accountability Act of 1996. A federal law that requires employers to provide certificates of coverage to minimize pre-existing condition exclusions.
Health Insurance: Protection that provides payment of benefits for covered sickness or injury. Included under this heading are various types of insurance such as accident insurance, disability income insurance, medical expense insurance, and accidental death and dismemberment insurance.
Health Maintenance Organization (HMO): An organization that provides a wide range of healthcare services for a specified group at a fixed periodic payment. The HMO can be sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies, and hospital-medical plans.
Hospice Care: A coordinated program at home and/or on an inpatient basis, offering easing of the patient’s pain and discomfort, and providing supportive care, for a terminally ill patient and the patient’s family, provided by a medically supervised specialized team under the direction of a licensed or certified hospice-care facility or agency.
In-Network Provider: Selected physicians who furnish a comprehensive array of healthcare services. Under contractual agreement, doctors accept the insurance carriers “Usual, Customary and Reasonable” amounts, as payment-in-full.
Inpatient Services: The care provided while a bed patient is in a covered facility. Provides extra benefits for services not covered at all by the base plan, and that in some cases pays balances of services not covered completely by the base plan; most are characterized by large benefit maximums, ranging from $250,000 to no limit; above an initial deductible, major medical reimburse the major percentage of all charges for hospital, doctor, private nurses, and so on; the policyholder insurer pays the remaining co-insurance.
Managed Care: Health-care systems that integrate the financing and delivery of appropriate health-care services to covered individuals by arrangements with selected providers to furnish a comprehensive set of health-care services, explicit standards for selection of healthcare providers, formal programs for ongoing quality assurance and utilization review, and significant financial incentives for members to use providers and procedures associated with the plan.
Medicaid: State programs of public assistance to people, regardless of their age, whose income and resources are insufficient to pay for health care. Title 19 of the federal Social Security Act provides matching federal funds for financing state Medicaid programs, effective January 1, 1966.
Medicare Supplements (Medigap): Policies sold by insurance companies that help supplement the amounts not paid by the Medicare program for covered services.
Medicare: The government health insurance system for people over the age of 65 (and for certain other groups), created by the 1965 amendments to the Social Security Act. This includes new coverage for prescription drugs under Medicare Part D.
Miscellaneous Expenses (Ancillary Charges): Hospital charges (other than room and board) such as for X-rays, drugs, and laboratory fees.
Open Enrollment Period: The period of time stipulated in a group contract in which eligible members of the group can choose a health plan alternative for the coming benefit year.
Out-of-Area Benefits: The scope of emergency benefits (and related limitations) available to HMO members while temporarily outside their defined service areas. Some HMOs offer unlimited out-of-area emergency coverage. Others impose a stated maximum annual dollar benefit. Emergency coverage is usually the only HMO benefit in the total benefit package for which members may need to file claim forms for reimbursement of their out-of-pocket expenditures for care.
Out-of-Network Providers: Physicians who do not participate in a contractual relationship to provide services and care for a predetermined amount to a carrier’s member.
Outpatient Services: The care provided to you in the outpatient department of a hospital, in a clinic or other medical facility, or in a doctor’s office.
Partial Disability: The result of an illness or injury that prevents an insured from performing one or more of the functions of his or her regular job.
Participating Physician: A doctor or supplier who agrees to accept Medicare assignment on all claims under the Medicare program. Agreement by which, under the contractual agreement, the doctors accept the insurance carriers usual, customary, and reasonable amount as payment in full.
Point-of-Service (POS): This product also may be called an open-ended HMO and offers a transition product incorporating features of both HMOs and PPOs. Beneficiaries are enrolled in an HMO but have the option to go outside the network for an additional cost.
Preadmission Certification: A procedure whereby (1) you or your doctor is required to contact your plan before your admission to a hospital, and (2) your plan determines the appropriateness of the admission and the length of stay by using established medical criteria.
Preexisting Condition: A physical and/or mental condition of an insured that first manifested itself prior to the issuance of his or her policy or that existed prior to issuance and for which treatment was received.
Preferred Provider Organization (PPO): A group of physicians and/or hospitals who contract with an employer to provide services to their employees. In a PPO the patient may go to the physician of his/ her choice, even if that physician does not participate in the PPO, but the patient receives care at a lower benefit level.
Premium: The fee you must pay (monthly, biweekly, quarterly) on a regular basis for your enrollment in a plan.
Prescription Drugs: Outpatient drugs and medicines which, by United States law, cannot be obtained without a doctor’s prescription.
Primary Care Network: The structure for these networks will vary considerably depending on the specific network. It may range from a loose association of physicians in a geographic area with a limited sharing of overhead, patient referral, call, etc. to a more structured association with commonly owned satellite clinics, etc.
Primary Care Physician (PCP): Provide treatment of routine injuries and illness and focuses on preventative care. Serves as gatekeeper for managed care. The American Academy of Family Practice defines primary care as “care from doctors trained to handle health concerns not limited by problem origin, organ systems, gender or diagnosis.”
Prior Authorization: Procedure used in managed care to control utilization of services by prospective reviewing and approval.
Providers: Those institutions and individuals who are licensed to provide health care services (for example, hospitals, skilled nursing facilities, physicians, pharmacists, etc.). Providers in a defined service area are principally owned by, affiliated with, employed by, or under contract to an HMO.
Service Area: The geographic area where prepaid plan (HMO) providers and facilities are available to you. This area would be the same as, or within, the plan’s enrollment area.
Total Disability: An illness or injury that prevents an insured person from continuously performing every duty pertaining to his or her occupation or engaging in any other type of work. (This wording varies among insurance companies.)
UCR (Usual, Customary, and Reasonable): A maximum payment allowed for a given medical service based on a statistical formula calculated by an insurance company to determine the amount it will pay on a given medical service.
Waiting Period: The length of time an insured must wait from his or her date of enrollment or application for coverage to the date his or her insurance is effective.