Service Employees 32BJ North Health Fund

Tri-State Preferred North Summary Plan Description (SPD) >> Other Health Plan Information You Should Know

• Assignment of Plan Benefits
• No Liability for Practice of Medicine
• Privacy of Protected Health Information
• Certificate of Creditable Coverage
• Converting to Individual Coverage

Assignment of Plan Benefits

You cannot assign or transfer benefits to anyone other than a health services provider (which you do by completing a claim form, which the provider of care will submit to the Plan, or by completing a form the Fund will provide). You cannot pledge the benefits owed to you for the purpose of obtaining a loan.

Benefits or payments under the Plan are not otherwise assignable or transferable, except as the law requires. Benefits also are not subject to any creditor’s claim or to legal process by any creditor of any covered individual, except under a Qualified Medical Child Support Order (QMCSO). A QMCSO is an order issued by a state court or agency that requires an employee to provide coverage under group health plans to a child.

A QMCSO usually results from a divorce or legal separation. Whenever the Fund Office gets a QMCSO, its qualified status is carefully reviewed by the Fund in accordance with QMCSO procedures adopted by the Board and Federal law. For more information on QMCSOs, or to obtain a copy of the Plan’s QMCSO procedures free of charge, contact the Fund Office at the address in the "Plan Facts" section.

No Liability for Practice of Medicine

Neither the Fund, the Board nor any of their designees:

• are engaged in the practice of medicine, nor do any of them have any control over any diagnosis, treatment, care or lack thereof, or any health care services provided or delivered to you by any health care provider, and

• will have any liability whatsoever for any loss or injury caused to you by any health care provider by reason of negligence, by failure to provide care or treatment, or otherwise.

Privacy of Protected Health Information

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law that imposes certain confidentiality and security obligations on the Fund with respect to medical records and other individually identifiable health information used or disclosed by the Fund. HIPAA also gives you rights with respect to your health information, including certain rights to receive copies of the health information that the Fund maintains about you, and knowing how your health information may be used. A complete description of how the Fund uses your health information, and your other rights under HIPAA’s privacy rules is available in the Fund’s “Notice of Privacy Practices,” which is distributed to all named participants. Anyone may request an additional copy of this Notice by contacting the Fund Office at the address in the "Plan Facts" section.

In April 2003, the Fund’s Board of Trustees adopted certain HIPAA privacy and security language that requires the Board of Trustees, in its role as Plan Sponsor of the Fund, to keep your health information private and secure. Any questions you may have about HIPAA may be directed to the Fund Office at the address in the "Plan Facts" section.

Certificate of Creditable Coverage

If you lose medical coverage, the Fund will issue you a Certificate of Creditable Coverage free of charge showing how long you were covered under this Plan. This Certificate enables you to receive credit toward any pre-existing condition exclusion under a new group plan or insurance policy.

This Certificate is available to you upon request by contacting the Fund Office at any point while you are covered under the Plan and up to 24 months after coverage ceases.

Please be advised that in any event, you will also automatically be provided with a Certificate of Creditable Coverage from the Fund and Empire when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage or when your COBRA continuation coverage ceases.

Converting to Individual Coverage

Procedures for converting to individual coverage are included in the Aetna Booklet.

All Other Plan Benefits. You cannot convert hospital, medical, prescription drug, EAP, dental, vision, short-term disability, or AD&PLC benefits to individual coverage.