2013 - Carroll Hospitalresource.carrollhospitalcenter.org/Documents/2013... · 2019. 1. 2. · This...

2013Together we make this the region’s best place to work.Six-time winner of the AWE Workplace Excellence Award.

Table of ConTenTs

2013BENEFITS GUIDE

03 Benefits enrollMent

08 Benefit overvieW

11 MeDiCAl insurAnCe

14 PresCriPtion PlAn

16 Wellness ProgrAMs

17 vision insurAnCe

18 DentAl insurAnCe

20 life insurAnCe

22 sHort-terM DisABility

23 long-terM DisABility

23 flexiBle sPenDing ACCounts

26 tuition AssistAnCe ProgrAMs

26 eMPloyee AssistAnCe ProgrAM (eAP)

27 retireMent sAvings PlAn

27 voluntAry Benefits AnD otHers

29 ContACt inforMAtion

31 iMPortAnt notiCes

37 notes

WELCOME + ii

Welcome

Dear Associate:

We are excited to provide you with critical information regarding your hospital-based benefits. This guide serves as a resource for your benefits information. Please put it in a place where you can easily access it later.

Associate benefits are a key aspect of your employment with Carroll Hospital Center and its affiliates. The information in this guide is intended to serve as a quick reference to your benefits and how to enroll. Please review this information thoroughly to ensure that you clearly understand the benefits offered to you by your employer.

This guide does not provide you with all of the details of each benefit offered through Carroll Hospital Center and its affiliates. More details can be found on the intranet by accessing the SPDs (Summary Plan Descriptions) and by using the links for our benefit vendors’ websites.

As always, the focus is on prevention and keeping our Associates healthy so we can care for the community. Care for yourself, so you can care for others.

Enrollment procedures appear on the next three pages of this guide. If you have any ques-tions, please contact the Human Resources Department at 410-871-7071 or 410-871-6837.

We wish you a happy and healthy 2013!

Sincerely, Meagan Enrique Director, Human Resources

Open Enrollment for 2013 Benefits

Open enrollment is your opportunity once a year to add, delete or change benefit elections. Meetings to review benefit offerings and explain any upcoming changes and enhancements will be held from October 15 through October 26, 2012. If you have questions during the open enrollment period please feel free to contact the Human Resources Department.

The open enrollment period for 2013 benefits is scheduled for October 15 through November 4, 2012. The enrollment process must be completed by November 4, 2012, for any changes to take effect following December 31, 2012.

Due to changes in benefits offerings, Associates must complete the 2013 open enrollment process even if they want to keep their current elections. Additionally, existing dependent or health care flex spending participants must reset their annual contribution limit.

Carroll Hospital Center, Carroll Hospice and Carroll Health Group Enrollment Process

Information needed to complete the enrollment process and instructions on how to access and navigate Lawson ESS can be found on pages 5 and 6.

New Hires or Changes in Benefit Eligibility

Associates who are actively budgeted to work full time (72-80 hours per pay period) or part time (40-71 hours per pay period) are considered benefit-eligible. There are some benefits that all Associates, including part time (less than 40 hours), PRN and Registry Associates, are eligible for.

New Hires

Most of your benefits become effective on the first day of the month following 30 days of employment.

Enrollment should be completed prior to the effective date to ensure that everything is in place once benefits are active. If you fail to complete enrollment by the end of the month during which your benefits first become effective, you will not be eligible to enroll in benefits again until the next annual enrollment period. Information needed to complete the enroll-ment process can be found on page 5.

3 + BEnEfits EnrOLLMEnt

Benefits enrollment

Any benefits-eligible Associate who does not complete the process will be assumed to be waiving all benefits. All Associates must complete this process via Lawson ESS.

Change in Benefit Eligibility Status

A transfer into a benefits-eligible position for the first time is a reason to complete the benefit enrollment process. In this type of situation, your benefits eligibility is effective the first day of the month following your status change. Generally, your benefit eligibility status will be set up in Lawson within the two weeks following your first day worked in a benefits-eligible role. If you do not complete the enrollment process in a timely manner, you will have the opportunity to select benefits during the next annual open enrollment period. Benefits elected during open enrollment periods become effective on January 1 of the following year.


Special Enrollment Due to Life Event

Once your enrollment elections become effective, you may not make changes until the next open enrollment period unless you experience a qualified change in employment or life status, such as:

• Marriage, divorce or legal separation

• Birth or adoption of a dependent or a qualified medical child support order

• Death of a dependent

• Loss of a dependent’s eligibility status (due to reaching age 26)

• A change in your spouse’s employment that results in a loss of eligibility for benefits through his or her employer

• Your spouse or dependent’s employer stops contributing toward coverage for you or your dependents

You must request enrollment within 30 days after the coverage for you or your dependents ends or after the date the employer stops contributing toward your current coverage.


BEnEfits EnrOLLMEnt + 4

Benefits enrollment (cont’d.)


important information needed for the enrollment process:1. Name, Social Security number and date of birth for all family members to be

covered under medical, vision or dental insurance.

2. Life insurance beneficiary designations require the name of your beneficiary(ies). Remember, your employer provides you with a basic life insurance policy; therefore, this information is important in order to complete the enrollment process.

3. Election of dependent or spouse life insurance requires the name and date of birth for each individual you cover.

Carroll Hospital Center, Carroll Hospice, and Carroll Health Group Enrollment ProcessTo enroll in benefits or to make changes to your current elections due to a change in eligibility, you will need to access Lawson Employee Self Service (ESS) at www.intra.carrollhospitalcen-ter.org and use the link at the top of the page. The enrollment site can easily be accessed from any computer with Internet Explorer. All computers at hospital workstations provide access to Lawson ESS. Computers are also available in the Human Resources Department.

To access Lawson ESS from outside the hospital use the site: http://extra.carrollhospitalcenter.org and select the Lawson tab.

You will be required to enter a Username, your Associate ID, and a password, which is unique to you. If you forget your password, submit a Helpdesk Work Order via the hospital intranet. The link is located at the top of the page. Once logged in, follow the instructions below to complete the enrollment process.

Please contact the Human Resources Department to provide the documentation for any of the previous changes within 30 days of the event. If you fail to declare a change within this time period, changes to your elections cannot be made until the next annual

open enrollment period. Only changes directly related to the qualified life status or employment change are permitted. For example, short-term disabil-ity coverage cannot be elected because of a marriage.

1. Log into Lawson ESS system- Username is your Associate ID - Password is unique to you

2. Select Employee Self Service from the left hand pane

3. Enroll Dependents- Select Personal Information and then Dependents - You must add/update any dependents that you want to cover before you enroll

4. Designate Beneficiaries- Select Benefits and then Beneficiary - You must add/update any beneficiary information

5. Enroll in Benefits- Select Benefits

- For open enrollment select Benefits Enrollment- For new hires select New Hire Enrollment- For change in eligibility select Newly Eligible- For special enrollment select Life Events from the ESS main menu

- Follow the on-screen instructions to complete your enrollment

BEnEfits EnrOLLMEnt + 6

Mandatory Wellness ScreeningOpen EnrollmentTo be eligible for benefits beginning on January 1, 2013, a wellness screening is required. You will not be eligible for Medical Insurance if a wellness screening is not completed by December 31, 2012.

Newly Eligible/New HireIf you are newly hired or become newly benefits eligible during the year, you have 30 days to complete a wellness screening for coverage eligibility.

Dependent VerificationAny Associate newly enrolling a dependent(s) on the medical, dental or vision plan must complete the steps listed below.

As part of our commitment to control health care costs, Carroll Hospital Center and its affiliates are taking steps to ensure that only eligible dependents are covered under our medical, dental and/or vision plans. To accomplish this, a dependent verification program has been implemented. This process is intended to ensure that each dependent enrolled in the Carroll Hospital Center medical, dental and/or vision plans is accurately listed and eligible for coverage.

Each employee must carefully review the definitions of an eligible dependent and verify that all dependents enrolled for coverage are eligible.

Benefits enrollment (cont’d.)


As a reminder, eligible dependents are defined as:

r Your legally married opposite sex spouse

r Your child up to age 26

r Your unmarried child of any age who is incapable of self-support due to a mental or physical disability and who receives more than half of his/her support and maintenance from the Associate

A child is defined as your natural child, legally adopted child, a child placed with you for adoption, stepchildren (as long as Associate is still married to the child’s natural or adopted parent) and/or a child for whom you are required to provide health insurance by a Qualified Medical Child Support Order.

Four steps are necessary:

1. Make sure that you have included legible copies of all required documentation (listed below)

2. Write your name and Associate number on each piece of documentation

3. Write “Not For Official Use” on each document and blacken out the first five digits of any Social Security number and any financial information, if applicable

4. Turn documentation into the Human Resources Department within 30 days or your dependents may not be eligible for coverage

Required Documentation:

Spouse:• A copy of your marriage certificate AND

• One form of documentation establishing current marital status such as a joint household bill, joint bank/credit account, joint mortgage or lease, or front page of your jointly filed federal tax return

Child:• A copy of the child’s birth certificate, naming you or your legally married spouse as

the child’s parent, or appropriate court order/adoption decree naming you or your legally married spouse as the child’s legal guardian

• Copy of the Qualified Medical Child Support Order showing you must provide coverage

BEnEfit OvErviEW + 8

Disabled Dependent (Over age 26):• A copy of the child’s birth certificate, naming you or your legally married spouse as

the child’s parent, or appropriate court order/adoption decree naming you or your legally married spouse as the child’s legal guardian AND

• A copy of the front page of the most recently filed federal tax return confirming this child as a dependent AND

• A medical providers documentation of disability

More details on each plan are included within the contents of this guide.

Benefit overvieW

Medical Plans – two options to choose from:1. Basic Plan – provider access available via two networks in addition to

out-of-network coveragenetwork Office visits: Primary Care & Specialist: 80% coverage after copay no deductible for Primary Care visits

Primary Care Wellness Visit: 100% coverage, no deductible

Deductible*: $600 individual/$1,200 family

Coverage: 70% for Carroll PHO Plus network after deductible 55% for United Healthcare Options PPO network after deductible 40% for non-network services after deductible

2. Premium Plan – provider access available via two networks in addition to out-of-network coverage

network Office visits: Primary Care & Specialist: 100% coverage after copay no deductible for Primary Care visits

Primary Care Wellness Visit: 100% coverage, no deductible

Deductible*: $300 individual/$600 family – Carroll PHO Plus network $400 individual/$800 family – United Healthcare Options

PPO network $600 individual/$1,200 family – Out-of-network

Coverage: 90% for Carroll PHO Plus network after deductible 75% for United Healthcare Options PPO network after deductible 60% for non-network services after deductible

Benefit overvieW

Benefit overvieW (cont’d.)

9 + BEnEfit OvErviEW

Prescription Plan (accompanies either medical plan)Deductible: $75 individual/$225 family

retail Pharmacy Co-pays: $10 for generic $35 for formulary $50 for non-formulary

Mail Order Co-pays (three-month supply): $20 for generic $70 for formulary $100 for non-formulary

Mail Order Program and Mandatory Generic:Please see more detailed information under the Prescription Plan section of this guide.

Vision PlanEye Exam (once every 12 months):

Co-pay: $10

Lenses/Contacts/Frames (once every 12 months): $130 allowance given towards a full set of glasses

$25 co-pay 20% discount for difference between allowance and actual cost

Dental PlanDeductible $50 individual/$150 family (applies to basic and major services)

Preventative Care (cleaning, routine exam):Coverage: 100% coverage, no deductible *Does not count towards annual maximum Additional cleaning covered during pregnancy

Basic Services (e.g. filling, root canal, oral surgery, extraction):network: 80% coverageOut-of-network: 60% coverage

Major Services (e.g. crown, bridge, onlay): network: 50% coverageOut-of-network: 40% coverage

Orthodontia for dependent children under 19 ($1,200 maximum lifetime benefit): network: 50% coverageOut-of-network: 40% coverage

BEnEfit OvErviEW + 10

Life Insurance and Accidental Death and Dismemberment

Basic Life Insurance and Accidental Death and DismembermentCoverage of one times your annual salary rounded up to the nearest thousand is provided by your employer.

Optional Life Insurance Supplemental life insurance coverage of one to four times your annual salary is also available. Evidence of Insurability is required if you were previously eligible for coverage and did not enroll or if you wish to increase coverage more than one increment of salary.

Dependent Life Insurancespouse Policy: Coverage in the amount of $15,000, $25,000 or $50,000; Evidence

of Insurability is required if you were previously eligible and did not enroll or if you wish to increase more than one level of coverage.

Dependent Policy: Coverage for your dependent child(ren) in the amount of $10,000

Short-Term Disability Benefits: 60% of your weekly salary up to $1,000 Benefits begin after 21 calendar days of disability Evidence of Insurability applies for any enrollment after initial eligibility

Long-Term Disability Benefits: Provided for full-time Associates 60% of your monthly salary up to $10,000 Benefits begin on 180th day of disability

Flex Spending Accounts – Health and Dependent Care Contribute up to $2,500 on a pre-tax basis for eligible health care and $5,000 for eligible dependent care expenses.

Tuition Reimbursement Traditional Tuition Reimbursement • Reimbursement of up to $3,000 for full time and $1,500 for part-time Associates

per year after completion of credited courses with a grade of C or better

• Associates must be benefit eligible and have successfully completed their intro-ductory period

11 + MEDiCaL insuranCE

Retirement Savings Plan (403b)A 403b is available to all Carroll Hospital Center and Carroll Hospice Associates for tax-free retirement savings. A 401k is available for Carroll Health Group Associates. Benefits-eligible Associates receive an employer match based on years of service. Enrollment can be completed at any time.

Voluntary Benefits • Auto/home insurance • Pet insurance • Pre-paid legal • And more!

disclaimer

This Benefits Guide provides an overview of many of the benefits offered by Carroll Hospital Center and its affiliates. In the event there is any discrepancy between the information in this guide and the plan documents or summary plan descriptions (SPDs) that govern the benefits plans, the information in the plan documents and SPDs, which can be accessed via the hospital’s intranet, will supersede. Any questions or concerns regarding the benefits offered by Carroll Hospital Center or its affiliates can be directed to the Human Resources Department at 410-871-7071 or 410-871-6837.

medical insurance

One of Carroll Hospital Center’s, and its affiliates’, highest priorities is to protect the health of Associates and their families by providing quality health insurance coverage at a reason-able cost. It is also important to recognize that choice and flexibility are integral to allowing an individual to access appropriate physicians and services.

Carroll Hospital Center and its affiliates offer the choice of two plans—Basic or Premium—through UMR, our medical benefits administrator.

Each plan allows you to access the Carroll PHO Plus and United Healthcare Options PPO networks, as well as providers who do not participate in either network. You need to select the plan that is best for you and any dependents you may cover. The decision you need to make involves the premium cost you want to pay up front and the cost sharing that is involved when you need to access care. You should consider how often you typically utilize health care services and how that utilization may affect out-of-pocket costs under each plan before making a final choice.

Both plan designs are established to give you and your fam-ily members access to providers who perform the services that are covered under the scope of the plan. Your level of coverage is determined by the plan you select and where the provider or facility falls within the network structure.

MEDiCaL insuranCE + 12

medical insurance

Neither plan requires referrals and wellness visits are covered at 100% of the usual, customary and reasonable charge for the Carroll PHO Plus and United Healthcare Options PPO networks.

Networks and Provider DirectoriesAn online provider listing can be accessed via the website www.umr.com. Select the tab “Find a Provider” on the left hand side of the page and then select “Medical”. This search tool will provide information regarding providers who participate in the PHO Plus and United Healthcare Options PPO networks. Searches can be done in many ways. You can search by location, physician name or specialty.

All Urgent Care Facilities are covered. However, some may require you to submit your own claim to UMR.

medical insurance (cont’d.)

13 + MEDiCaL insuranCE

Service Carroll PHO Plus

United Healthcare All Others Carroll

PHO PlusUnited Healthcare All Others

Deductible individual family

$600$1,200

$600$1,200

$600$1,200

$300$600

$400$800

$600$1,200

Co-Insurance (plan pays) 70% 55% 40% 90% 75% 60%

Out of Pocket Maximum individual family

$3,000$6,000

$5,000$10,000

$7,000$14,000

$2,000$4,000

$4,000$8,000

$6,000$12,000

Hospital

70% after $500 per confinement co-pay (deductible waived)


40% after $500 per confinement co-pay (deductible waived)*

90% after $500 per confinementco-pay (deductible waived)


60% after $500 per confinement co-pay (deductible waived)*

Emergency Room

70% after $150 co-pay (deductible waived)


70% after $150 co-pay (deductible waived)*




Inpatient Surgery

70%(deductible waived)


40%(deductible waived)*



60%(deductible waived)*

Urgent Care







Surgery Center 70% 55% 40% 90% 75% 60%

table 1 Basic plan premium plan

PrEsCriPtiOn PLan + 14

Office VisitCoverage Primary Care

specialist


80% after $25 co-pay



40% after deductible*








Primary Care - Wellness

100% no co-pay (deductible waived)






Specialist - Wellness







prescription plan

A prescription plan, through Express Scripts, Inc., is included with both medical plans offered to benefits-eligible Associates.

This prescription plan is designed to provide coverage for the medication needs of par-ticipating Associates and their covered dependents. Using generic medications whenever possible can lower your out-of-pocket costs. Walgreens pharmacies are not included in the plan.

Mandatory Generics Program – This program mandates automatic generic substitution for brand-name medications when a generic medication is available. If a plan participant chooses to fill the brand medication instead of the generic, an ancillary charge will be passed

This grid is not all inclusive. Please refer to the Summary Plan Description for more detail.

* Represents coverage at the usual and customary charge for the services rendered. If your out-of-network provider charges more than the usual and customary limit, those charges will not be covered by the plan, and you may be balance billed.

prescription plan

prescription plan (cont’d.)

15 + PrEsCriPtiOn PLan

Basic plan premium plan

table 1 Standard Rates

Coverage Level Full Time Part Time Full Time Part Time

individualassociate and Childassociate and spousefamily w/2 dep.family w/3 dep.family w/4+ dep.family w/5+ dep.

$31.16$59.20$65.44$95.39$103.34$111.29$120.87

$42.21$80.20$88.64$128.52$139.23$149.94$161.16

$56.85$108.02$119.39$172.67$187.05$201.44$216.50

$76.46$145.27$160.56$231.46$250.75$270.05$288.15


table 2 Nicotine Test – 5% Reduction



$29.60$56.24$62.17$90.62$98.17$105.73$114.83

$40.10$76.19$84.21$122.09$132.27$142.44$153.10

$54.01$102.62$113.42$164.03$177.69$191.37$205.68

$72.64$138.01$152.54$219.89$238.22$256.54$273.74

on. The ancillary charge is the difference between the cost of the brand-name medication and the generic, and will be added to the brand co-pay.

Home Delivery – This program allows maintenance prescriptions to be filled by Express Scripts Home Delivery. By utilizing this benefit, a three-month supply of medications is received for the cost of two-months.

Step-Therapy Program – This program is for newly prescribed medications to assist users in accessing the most cost-efficient, effective medications possible.

Prescription Costs: Deductible: $75 individual/$225 family

retail Pharmacy Co-pays: Mail Order Co-pays (three-month supply for two-month co-pay) Generic $10 $20 Formulary $35 $70 Non-Formulary $50 $100

Medical ID CardsID cards contain both medical and prescription information. Contact information for UMR and Express Scripts networks are listed on the ID card.

Wellness programs

The hospital has a formal wellness program to encourage participation in activities and behaviors that improve health and well-being, and to provide the resources and education to do so. The concept of a wellness program is to address not just physical health, but also mental and emotional health. Wellness brings balance to your life and helps you take better care of yourself.

Throughout the year, there will be activities, educational sessions and informational fairs to provide Associates opportunities to learn more about health issues and how to bring balance to their lives. These opportunities are open to all Associates.

Wellness programs

WELLnEss PrOgraMs + 16


table 4 Nicotine Test & Wellness Credits – 15% Reduction



$26.48$50.32$55.63$81.08$87.84$94.60$102.74

$35.88$68.17$75.34$109.24$118.34$127.45$136.99

$48.32$91.81$101.48$146.77$158.99$171.22$184.03

$64.99$123.48$136.48$196.74$213.14$229.54$244.93


table 3 Wellness Credits – 10% Reduction



$28.04$53.28$58.90$85.85$93.01$100.16$108.78

$37.99$72.18$79.77$115.67$125.31$134.95$145.04

$51.16$97.21$107.45$155.40$168.34$181.29$194.85

$68.82$130.75$144.51$208.32$225.68$243.04$259.34

vision insurance

17 + visiOn insuranCE

A wellness screening will be required of all Associates who carry medical insurance with Carroll Hospital Center on an annual basis to provide an opportunity for individuals to learn about any chronic illnesses or health risks they may face. In keeping with our culture of health and well-being, we feel that all Associates should have the opportunity to learn about any chronic health conditions or health risks which may be detected through annual health assessments. Associates who are screened and identified as being high risk may ben-efit from the Hospital’s care management programs. As a result, you and your family may be placed in the Enhanced plan. While in this program, you will be provided personalized care management of your health conditions, and your employer will waive the prescription copays for the following therapeutic drug classes: high blood cholesterol, high blood pres-sure, heart disease and diabetes. As an employer who cares for our Associates, we hope that this benefit enhancement will allow you to concentrate on your health and alleviate some of the burden or expense associated with medications to treat or manage your health condi-tions. The goal of this program is to work with you and eventually assist you to get to a place in health where you are “Living Well for Life.”

All new hires are eligible to begin taking advantage of the wellness activities and programs immediately. Newly hired Associates can contact Associate Health directly at x6846 to make a wellness appointment. To be eligible for health insurance, a new hire must complete a Health Risk Assessment with Associate Health within 30 days of their hire date.

We look forward to engaging all Associates in this program and hope that there is a far-reaching positive impact for everyone at Carroll Hospital Center, Carroll Hospice and Carroll Health Group.

vision insurance

The vision plan is provided through VSP and offers the following coverage:

• Eye Exam (available every 12 months) – $10 co-pay

• Frames (available every 12 months) – $25 co-pay

• Lenses (available every 12 months) – $25 co-pay (may be combined with frames)

• Contacts (available every 12 months) – no co-pay applies

The theme of the wellness program is Live Well…for Life because we want Associates to maintain or improve their cur-rent health status or make positive changes to their lifestyles and behaviors in order to maintain good health and quality of life on a long-term basis. Care for yourself so you can care for others.

DEntaL insuranCE + 18

Another exciting feature of this plan is that all Associates, includ-ing those who are not benefits eligible, are automatically entitled to a 20% discount on services and materials from any VSP provider by mentioning that they are employed by Carroll Hospital Center.

dental insurance

table 5 Vision Insurance Bi-weekly Premiums

Level of Coverage Full or Part Time

Individual $3.22

Associate and Spouse $6.44

Associate and Child(ren) $6.89

Family (3 or more) $11.02

• If there is a balance after the $130 allowance for hardware (lenses and frames) is met, a 20% discount will apply

• Laser vision correction discounts

• A list of participating providers can be accessed at www.vsp.com

dental insurance

With the United Concordia Preferred Dental Plan, you are able to visit any licensed dentist but can maximize the coverage and convenience by using a participating dentist. For a participat-ing dentist, you simply need to present your dental card. When visiting a non-participating dentist, you will not only be responsible for an increased portion of the costs via a higher co-insurance and the dentist’s ability to balance bill, but you may also need to submit a claim form to United Concordia for reimbursement. Forms are available via the intranet or from the Human Resources Department.

Another feature of the United Concordia Plan is the ability to access your dental information using My Dental Benefits at www.ucci.com. This website allows you to identify providers, check on your claim status and eligibility, print a replacement dental card and map a route to your dentist’s office. The network for the plan is the United Concordia Advantage Plus Network. By accessing this network, you will receive the maximum level of coverage.

19 + DEntaL insuranCE

dental insurance (cont’d.)

table 7 Dental Insurance Bi-weekly Premiums

Level of Coverage Full Time Part Time

Individual $7.02 $9.13

Associate and Child $13.75 $17.18

Associate and Spouse $17.18 $21.47

Family w/ 2 Dep $22.33 $27.97

Family w/ 3 Dep $24.08 $29.89

Family w/ 4 Dep $25.32 $32.17

Family w/ 5 Dep $27.31 $34.69

table 6 Dental Plan Summary

* Represents coverage at the usual and customary charge for the services rendered. If your out-of-network provider charges more than the usual and customary limit, those charges will not be covered by the plan, and you may be balance billed.

* *Additional cleaning covered during pregnancy

Service In Network Out-of-Network

Annual Deductible individual family

$50$150

$50$150

Annual Maximum $1,000 per person $1,000 per person

Preventative Care** Does not count towards annual max. 100% 100%*

Basic Services 80% after deductible 60% after deductible*

Major Services 50% after deductible 40% after deductible*

Orthodontia($1,200 maximum lifetime benefit)

50% 40%*

LifE insuranCE + 20

life insurance

Basic Life Insurance/Accidental Death and Dismemberment (AD&D)Benefits-eligible Associates are provided with life insurance and AD&D coverage equal to one times their base annual salary rounded up to the nearest thousand (maximum benefit of $100,000). If the Associate dies while covered under this plan, the designated beneficiary(ies) will receive the basic life insurance coverage amount. If an accidental death occurs, the beneficiary(ies) will receive the AD&D coverage amount in addition to the basic life insurance benefit amount.

Supplemental Life InsuranceAssociates may elect supplemental life insurance coverage up to four times their annual sal-ary (maximum benefit of $500,000). Cost for this coverage is based on age and annual salary. Premiums are paid on a post-tax basis, so benefits are not taxable to designated beneficiary(ies) in the event of the Associate’s death. Aetna provides a guaranteed issue of up to four times the Associate’s annual salary or a maximum of $500,000 if elected when first eligible.

If an Associate elects to increase the covered amount by more than one times their annual salary following their initial election, Evidence of Insurability will be required. The forms that need to be completed can be obtained on the hospital’s intranet site under Human Resources, Benefits Information or from the Human Resources Department. The hospital and its affiliates have no influence regarding determination of insurability. The insurance company reviews the Evidence of Insurability and makes a determination regarding coverage level.

How to Calculate Your Supplemental Life Insurance Premium:A. Multiply annual salary by the elected level of supplemental life insurance (1, 2, 3 or 4):

$_____________

B. Round the above figure up to the nearest thousand: $______________

C. Divide by 1,000: _________________

D. Multiply C by the rate indicated in the table for your age group: $_______________

E. Divide by 2

F. Multiply E by 24

G. Divide F by 26: $_______________ = cost per pay

life insurance

21 + LifE insuranCE

life insurance (cont’d.)

table 8 Cost per $1,000

Your Age Cost per $1,000 Your Age Cost per $1,000

Under 30 $0.03 50 – 54 $0.23

30 – 34 $0.04 55 – 59 $0.34

35 – 39 $0.05 60 – 64 $0.49

40 – 44 $0.08 65 – 69 $0.74

45 – 49 $0.15 70 – 74 $1.12

dependent life insuranceYou may also purchase life insurance for your spouse and dependent children. This coverage will pay a benefit to you upon the death of the insured. You pay the full cost of the benefit on a post-tax basis.

Spouse Coverage: You can elect coverage for your spouse in the following amounts: Coverage rate $50,000 $2.20 per pay

$25,000 $1.10 per pay

$15,000 $0.67 per pay

Coverage on a spouse cannot total more than basic plus supplemental life insurance coverage on the Associate.

Child(ren) Coverage: Eligible children include your children by birth, adoption, placement for adoption or legal guardianship, who are under age 26. If you elect this coverage, all of your eligible children will be covered.

Coverage rate $10,000 $0.70 per pay

sHOrt-tErM DisaBiLity + 22

short-term disaBility

short-term disaBility

The short-term disability plan provides income protection for Associates who have an illness or injury that keeps them away from work for more than 21 days. The short-term disability plan will replace 60% of an Associate’s base weekly earnings up to $1,000. Benefits begin on the 22nd day of disability and are payable up to the 179th day.

Use the guide below to calculate your post-tax cost for short-term disability:

A. ____________ multiplied by _______________ : $____________ (Hourly Rate) (Weekly Hours)

B. Multiply A by 60% (.60): _____________________

C. Divide B by 10: _________________

D. Multiply C by $0.53: _____________

E. Multiply D by 12

F. Divide E by 26: _______________ cost per pay

To access this benefit, an Associate must contact Aetna at 1-866-326-1380 to file a claim. It is important to remember that Associates must apply for short-term disability benefits no more than 10 days beyond their 21-day elimination period.

Eligibility: The effective date for Associates enrolling in the short-term disability plan is the first of the month following 90 days in a benefits-eligible status.

If an Associate newly elects short-term disability coverage following their initial eligibility, Evidence of Insurability will be required. The Evidence of Insurability form can be found on the hospital’s intranet under Human Resources. The hospital and its affiliates have no influ-ence regarding determination of insurability. The insurance company reviews the Evidence of Insurability and makes a determination regarding coverage. You will not be charged or cov-ered by short-term disability coverage until Aetna has received and approved your Evidence of Insurability form.

23 + LOng-tErM DisaBiLity

long-term disaBility

long-term disaBility

Carroll Hospital Center and its affiliates provide long-term disability coverage for full-time Associates. If you have an illness or injury that lasts longer than 179 days, this plan replaces 60% of your base monthly pay up to a monthly maximum of $10,000. Benefits under this plan normally continue until:

• The date you are no longer disabled

• The date you reach Social Security age

• The date you die

flexiBle spending accounts

Health Care SpendingThe health care flexible spending account allows you to set aside a maximum of $2,500 pre-tax to pay for certain health care expenses that are not covered by insurance, such as plan deductibles, co-insurance or co-pay(s), vision care and dental care.

Normally, you can claim eligible uninsured health care expenses that are more than 7.5% of your adjusted gross income when you file income taxes. In most cases, you will save more on taxes by using a health care spending account. For more detailed information on eligible expenses, visit CBIZs’ website at www.myflexonline.com.

Claims can be made for the following individuals: you, your spouse, your children/dependents (must meet dependent eligibility requirements) or anyone else you claim as a dependent on your federal tax return.

Use it or Lose it: It is very important that you carefully estimate your annual eligible expenses for health and dependent care, and deposit only the money that you expect to use. Otherwise, there will be money remaining after all of your expenses have been reim-bursed. Federal law prohibits employers from leaving the money in the account for the following year or paying it directly to you. This is the “use it or lose it” rule.

Please note that annual testing, as directed by the IRS, is conducted for flexible spending accounts that may adversely affect Highly Compensated Employees (HCE), defined by the IRS as individuals who make $110,000 or more for 2013. The impact may be that an HCE is limited as to the amount of deferral that can be made into an FSA based on ratios of HCEs and non-HCEs who participate in the plan. We are unable to provide information regarding how a specific individual will be impacted until the testing is completed.

fLExiBLE sPEnDing aCCOunts + 24

The amount of pre-tax dollars you choose to contribute to your health care spending account remains the same for the entire year. You can make changes to your annual contribution only if one of the following occurs: birth or adoption of a child, death of your spouse or a child, as the result of FMLA or loss of your spouse’s employment.

When you incur eligible expenses, you can use your Flex Account Debit Card or complete a Health Care Spending Account Reimbursement form (available on the CBIZ website, www.myflexonline.com, on the hospital’s intranet site or from the Human Resources Department). The Flex Account Debit Card allows you to pay your expenses at the point of service. Substantiation is typically required. This follow-up documentation is required by the IRS. If you prefer to submit a paper claim, send your completed claim form and receipts to CBIZ, using the address shown on the form, or fax your information to 800-584-4185.

Please note that services or purchases eligible for reimbursement must be rendered during the period the plan participant is active in the plan. Claims can be reimbursed only if they are incurred in the year in which the contributions are made. However, you have 90 days after the end of the calendar year to submit receipts for expenses incurred during that year. Use caution when using your debit card soon after the year begins as charges are often for the previous year.

Associates participating in the health care flexible spending account program can access information regarding their account at any time online at www.myflexonline.com or by con-tacting CBIZ at 800-815-3023.

Dependent Care Spending

The dependent care flexible spending account allows you to set aside a maximum of $5,000 pre-tax to pay for dependent care inside or outside your home.

According to current law, you are eligible to open such an account if you have live-in depen-dents who require care either inside or outside your home. Dependents are: your children under age 13 and/or disabled dependents of any age (such as your disabled spouse, older child, or parent).

Dependent Care Spending is an excellent way to save while you spend. This account can even be used for summer camps.

Health Care Spending is an important tool to assist in reducing more out-of-pocket medical costs.

25 + DEPEnDEnt CarE sPEnDing

dependent care spending

You can be reimbursed only for care that enables you to work. If you are married, your spouse must also work, be a full-time student or disabled. Eligible care includes care in your home, someone else’s home, a licensed care facility or day camp.

You can be reimbursed for care provided by a relative, as long as the person is not your spouse, your child under age 26 or someone you claim as a dependent on your federal income tax return.

When you pay your dependent care expenses, be sure to ask your provider to complete and sign the Dependent Care Flexible Spending Account Reimbursement form or for a receipt showing a Social Security or Tax ID number. If your provider issues a receipt, attach it to a completed Dependent Care Flexible Spending Account Reimbursement form, which can be obtained from the CBIZ website, www.myflexonline.com, the hospital’s intranet site or the Human Resources Department. You can submit your completed form to CBIZ by mail-ing it and your receipts to the address shown on the form or by faxing the information to 800-584-4185.

You can be reimbursed up to the balance of your account; you’ll be reimbursed for any remaining expenses that are above and beyond the account balance as deposits are made through payroll deductions.

The amount of pre-tax dollars you choose to deposit into the dependent care spending account can be adjusted only if your dependent care situation changes. The following are examples of changes that would permit an adjustment: unexpected increase or decrease in cost, loss of dependent care provider or transfer to a new provider.

Associates participating in the dependent care flexible spending account program can access information regarding their account at any time online at www.myflexonline.com or by con-tacting CBIZ at 800-815-3023.

Please note that annual testing, as directed by the IRS, is conducted for flexible spending accounts that may adversely affect Highly Compensated Employees (HCE), defined by the IRS as individuals who make $110,000 or more for 2013. The impact may be that an HCE is limited as to the amount of deferral that can be made into an FSA based on ratios of HCEs and non-HCEs who participate in the plan. We are unable to provide information regarding how a specific individual will be impacted until the testing is completed.

tuitiOn assistanCE PrOgraMs + 26

tuition assistance programs

tuition assistance programs

Carroll Health Center, Carroll Hospice and Carroll Health Group will financially assist benefits-eligible Associates who are pursuing a degree or certification.

Tuition Option A: Associates participating in this program must be benefits eligible and have successfully completed their introductory period. Classes eligible for reimbursement must begin once the introductory period is complete. Full-time Associates are eligible for $3,000 per calendar year, while part-time Associates can be reimbursed up to $1,500 per calendar year. Approval of the class must be submitted and approved by the Human Resources Department two weeks prior to the class beginning. Reimbursement occurs after completion of the credited course with a grade of C or better and proof of payment. Please note that only credit costs are reimbursable under this option.

Certification Reimbursement: Available for certifications directly related to the Associate’s cur-rent position. Reimburses cost of exam and/or certification.

For more information regarding these programs, please refer to the Tuition Assistance Programs policy or contact Human Resources.

employee assistance program (eap)The EAP through ComPsych provides professional support services to help Associates, their household members and dependent children cope with a variety of personal and career-related issues. The EAP offers assistance with confidential counseling sessions with a master’s or doctoral-prepared professional, as well as financial and legal issues. The pro-gram is available 24 hours a day, seven days a week, and is completely confidential. The EAP also offers personal concierge service that can assist when purchasing a car, planning home renovations, booking travel, etc.

If you have an issue and need professional, confidential help, please contact ComPsych at 1-866-827-7635 or visit www.guidanceresources.com.

As an Associate, you are able to receive information and support on issues such as will preparation, credit issues, substance abuse, child or elder care and other personal convenience services at no cost to you.

27 + rEtirEMEnt savings PLan

retirement savings plan

retirement savings plan

Your employer has established a retirement savings plan in the form of a 403b or 401K to allow Associates to save for retirement using pre-tax contributions. An employer match is provided for all benefits-eligible Associates.

Hospital and hospice Associates who work at least 1,000 hours in a calendar year will also receive an employer base contribution. The level of these discretionary contributions will be determined on an annual basis.

This program is offered through Diversified Investment Advisors. Mutual funds using differ-ent styles of investment, including lifestyle funds, are offered. There is a representative on site on a regular basis to meet with Associates to assist in plan enrollment, balancing portfolios and/or investment advice. The Diversified representative can be reached by dialing x6030 to help with enrollment, rollovers and other retirement-related questions. More information regarding the plan can be obtained at www.divinvest.com. You can also enroll and access your account by visiting this website. Printed enrollment kits and fund information can be obtained in the Human Resources Department.

Enrollment and changes to 403b and 401k contributions and investment selections can be made at any time.

voluntary Benefits and othersCarroll Hospital Center and its affiliates offer voluntary benefits in addition to the traditional benefits package. As a hospital or affiliate Associate, you have access to: group auto/home insurance, pre-paid legal, pet insurance and others. Some of these offerings provide the opportunity for the convenience of payroll deduction. See below for more details.

Auto/Home Insurance Compare your current auto, renter’s and home insurance rates to the group rates for coverage available to you through MetLife. By calling 1-800-GET-MET8 or visiting www.metlife.com/mybenefits, you can obtain a real-time quote based on your personal situation.

Credit Union Membership Carroll Hospital Center and its affiliates offer all Associates the opportunity to join First Financial Federal Credit Union. The credit union offers many free, no-hassle products and services. As a member, you have access to a free checking account that requires no

vOLuntary BEnEfits anD OtHErs + 28

minimum balance and pays you interest on all monies in the account. In addition, First Financial Federal Credit Union offers various savings options and a multitude of loan servic-es. To open an account with the credit union, an Associate must complete the membership application and make a $5 deposit. Membership applications can be obtained by contacting First Federal Financial Credit Union at 410-321-6060 or the Human Resources Department. For more information, visit www.firstfinancial.org.

Discount Tickets The Human Resources Department offers discount tickets to several of the area’s most pop-ular theme parks. If you are not a ride enthusiast, you may enjoy some of the other discount tickets that are offered. In the winter, lift tickets and ski rentals can be purchased. Movie passes to AMC Theaters (Owings Mills) and Regal Cinemas (TownMall of Westminster) are available year-round. All of these tickets can be purchased with credit card or check from the Human Resources Department. For information and pricing, refer to the hospital’s intranet.

MetDESK MetDESK is a free service that provides support, referrals and resources to parents and fami-lies of special needs children. This program is available to all Associates who have a special needs child and need assistance in planning for the future. For details, call 1-800-GET-MET8 or visit www.metlife.com/mybenefits.

MetLife Advice MetLife Advice is a free service that uses an educational approach to help Associates make informed benefits and financial decisions regarding retirement, college funding strategies, financial management, estate conservation and investment fundamentals. Simply contact a dedicated MetLife Advice specialist at 1-800-GET-MET8 or visit www.metlife.com/mybenefits.

Pet Insurance We are excited to offer affordable veterinary insurance for your pets. This coverage is available for dogs and cats beginning at six weeks of age, as well as a variety of other pets, including birds, snakes and potbelly pigs. More information regarding this insurance can be obtained by calling 1-800-GET-MET8 or by visiting www.metlife.com/mybenefits.

Pharmacy Discount Benefits Associates receive a 10% discount on over-the-counter items at Anchor Pharmacy in the Washington Heights Medical Center when they present their badge.

Pre-Paid LegalFor less than $1 per day, you can have legal advice and access to an attorney at your fingertips through Hyatt Legal. By visiting www.metlife.com/mybenefits or calling 1-800-GET-MET8, you can learn more about the pre-paid legal plan and services available to you.

voluntary Benefits and others

29 + COntaCt infOrMatiOn

contact information

Human Resources Link on the Hospital’s Intranet www.intra.CarrollHospitalCenter.org

Extranet http://extra.CarrollHospitalCenter.org

Human Resources – Benefits: Benefits Team Leader 410-871-7071

CHG HR Business Partner 410-871-7591

Director, Human Resources 410-871-6837

Auto/Home Insurance: MetLife 1-800-GET-MET8 www.metlife.com/mybenefits

Credit Union: First Financial Federal Credit Union 410-321-6060 www.firstfinancial.org

Dental Insurance: United Concordia 1-866-215-2351 (Advantage Plus Network) www.ucci.com

Disability Programs (short term and long term): Aetna 1-866-326-1380 www.aetna.com/group/aetna_life_essentials

Employee Assistance Program (EAP): ComPsych – Guidance Resources 1-866-827-7635 (company ID: CARROLL) www.guidanceresources.com

Flexible Spending Accounts: CBIZ 1-800-815-3023 www.myflexonline.com

FMLA Requests: FMLA Source 1-877-GO2-FMLA www.fmlasource.com

contact information

COntaCt infOrMatiOn + 30

Life Insurance: Aetna 1-800-523-5065 www.aetna.com/group/aetna_life_essentials

Medical Insurance: UMR 1-800-826-9781 www.umr.com

Pet Insurance: MetLife 1-800-GET-MET8 www.metlife.com/mybenefits

Pre-Paid Legal Services: Hyatt Legal 1-800-GET-MET8 Company Access Code: 571687 www.metlife.com/mybenefits

Prescription Coverage: Express Scripts 1-877-206-7432 www.express-scripts.com

Retirement Savings Plan: Diversified Investment Advisors 1-888-676-5512 www.divinvest.com

Vision Insurance: VSP 1-800-877-7195 www.vsp.com

31 + iMPOrtant nOtiCEs

important notices

important notices

COBRA – Benefit ContinuationIf you elected medical, vision or dental coverage under the Carroll Hospital Center plan, you have the right to continue that coverage at the group rate if your coverage is lost due to a reduction in hours or termination of employment. Your covered dependents also have the option to continue the coverage through Carroll Hospital Center and its affiliates if the cover-age is lost due to one of the following reasons:

• Death of spouse/parent (covered Associate)

• Termination of spouse/parent employment with Carroll Hospital Center, Carroll Hospice or Carroll Health Group

• Loss of benefits-eligible status

• Reduction in work schedule for Associate of Carroll Hospital Center, Carroll Hospice or Carroll Health Group

• Divorce or legal separation

• Eligibility for Medicare

• Dependent child no longer qualifies as a dependent as defined by the plan

In order to be considered an eligible dependent, the individual must generally be covered under the group health plan the day before the event that causes the loss of coverage, unless a child is born or adopted by a covered Associate during the period of COBRA coverage.

Associate’ s ResponsibilitiesAs an Associate, it is your responsibility to notify Carroll Hospital Center or its affiliates within 30 days of a divorce, legal separation, loss of dependent status or other qualifying event. After Carroll Hospital Center or its affiliates are notified, you will be provided with information from the carrier regarding your options to continue your group health coverage. You have 60 days from the date your coverage ends or the notification date from the plan, whichever is later, to decide whether you want to continue the coverage. If you decide not to continue coverage through the Carroll Hospital Center plan, your group health coverage will end.

If you choose to continue your coverage, Carroll Hospital Center or its affiliates are required to provide coverage identical to the coverage you maintained prior to your qualifying event. The law requires you to be permitted to continue coverage for three years unless the loss of coverage results from termination or reduction in hours. In that case, the required continuation period is 18 months, which can be extended up to 36 months if other events (death, divorce, legal separation or Medicare eligibility) occur during that 18-month period.

iMPOrtant nOtiCEs + 32

If an individual is disabled prior to or becomes disabled (as determined by the Social Security Administration) within the first 60 days of their COBRA coverage, in addition to satisfying the applicable notice requirements, the plan will extend the 18-month continuation period to 29 months. If the disabled Associate also covers family members, the family members will also be extended the 29-month coverage period. Carroll Hospital Center or its affiliates must be noti-fied within 30 days of the final determination that they are no longer disabled.

Termination of Coverage Under COBRAYour coverage can be terminated for any of the following reasons:

• The premium for your coverage is not paid on time

• You become eligible for Medicare

• Your continuation period expires

• You extend your coverage for 29 months due to disability and a determination is made that you are no longer disabled

Carroll Hospital Center’s, and Its Affiliates, RightsCarroll Hospital Center and its affiliates can stop making COBRA coverage available to a covered individual when coverage becomes available under another group health plan (unless the new plan has a pre-existing condition clause) or if they stop offering a group health plan in total.

Women’s Cancer RightsWOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998If you have had, or are going to have, a mastectomy, you may be entitled to certain ben-efits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: 1) all stages of reconstruction of the breast on which the mastectomy was performed, 2) surgery and reconstruction of the other breast to produce a symmetrical appearance, 3) prostheses and 4) treatment of physical complications at all stages of the mastectomy, including lymphedemas.

These benefits will be subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under your elected medical plan.

If you would like more information on WHCRA benefits, call the Human Resources Department at 410-871-7071.


important notices (cont’d.)

Women’s and Newborns’ RightsGroup health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or new-born child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s 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). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

HIPAAThe Carroll County Health Services Corporation Group Health and Welfare Plan has the duty to protect your medical information. The plan further has the duty to provide you with a notice of its privacy practices, which follows. The plan has the right to change or modify this notice, at any time, and any modifications will be communicated to you. This notice describes how your medical information may be used and disclosed, and how you can get access to it. Please review it carefully.

NOTICE OF PRIVACY PRACTICESThe Health Insurance Portability and Accountability Act limits how a covered entity can use and disclose protected health information (PHI). Generally, a covered entity, including your health plan, health care provider or a health care clearinghouse, can share information with-out your authorization for treatment purposes, payment for your medical services and for the health plan’s operation. In all other instances, you must authorize any disclosure of your health information.

Permitted DisclosuresThe plan can use and disclose your PHI for the following purposes, without your authoriza-tion, for making or obtaining payment for your health care and for conducting health plan operations.

Examples of when and how your PHI can be used and disclosed for payment purposes without your authorization are:

• For coordination of benefits among multiple plans that cover you

• For utilization review purposes

• For case management purposes

• For precertification purposes

• Any other purpose necessary to ensure coverage for you and to obtain or make payment for services rendered to you


Examples of when and how your PHI can be used and disclosed for health plan opera-tions, without your authorization, are:

• To ensure coverage for you

• For quality assessment purposes

• For cost-containment purposes

• To ensure compliance with the terms of the plan or with clinical or other relevant medical guidelines and protocols

• To provide you with treatment alternatives

• For underwriting, premium rating and related functions

• To create, renew or replace your health insurance or health benefits

• To conduct audits, including compliance, medical, legal, business planning, cost containment or customer service audit functions

The plan can share your PHI with the plan sponsor for certain administrative activities, without your authorization. Examples of sharing PHI include, but are not limited to:

• Seeking premium bids for current or future coverage

• Obtaining reinsurance

• Amending, modifying or terminating the plan

• Participant and enrollment information

Your PHI can be released in summary form or as a part of “de-identified” information in accordance with the Code of Federal Regulations.

Other instances in which your PHI may be released, without your authorization, include:

• When legally required by federal, state or local law. This instance would include the release of PHI upon the receipt of an order, subpoena or other judicial or administrative process that would compel the disclosure of your PHI. However, your PHI would only be disclosed after a reasonable effort has been made to notify you of the request for such information.

• For law enforcement purposes, such as investigation of a crime

• To respond to a threat to public health or safety

• For workers compensation purposes or other no fault law

• To a government authority, such as a social service or other protected services organization, authorized to receive reports of abuse, neglect or domestic violence


Authorization for Use and DisclosureExcept as provided above, the plan will not release any of your PHI without your authorization. If you authorize the release of some or all of your PHI, you may revoke the authorization at any time. If you authorize release of your PHI, your authorization must include the following items:

1. A description of information used or disclosed

2. Identification of the parties releasing and the parties requesting the information

3. An expiration date of the authorization

4. Your signature

5. Information about how to revoke the authorization

Your Individual Rights under HIPAAYou have certain individual rights regarding your PHI, specifically:

1. If the plan maintains your PHI, you have the right to inspect and request a copy of it. The plan may charge a reasonable fee for copying this information. If the plan does not maintain the PHI, which is the subject of your request, you will be directed to the appropriate party who can assist you with your inquiry.

2. You have the right to request restriction of the use and disclosure of your PHI, although the plan is not required to agree with your request.

3. You have the right to receive confidential communications. You have the right to limit or restrict where, or how, the plan may contact you regarding your PHI.

4. You have the right to request amendments or modifications to your PHI. If you believe your PHI is inaccurate or incomplete, you have the right to request an amendment to your records. In order to be entitled to amend the records, the plan must maintain the relevant records, and you must make the request for amendment in writing. The plan has the right to deny your request to amend or modify your PHI if:

A. You do not have a substantive reason for the request

B. The relevant records were not created by the plan

C. The request falls within an exception to the amendment rights provided by the law

D. It is determined that the information is complete or accurate

important notices (cont’d.)


You have the right to obtain an accounting of any disclosure that has been made of your PHI, other than those disclosures made for health care payment, treatment or other health care plan operations. To exercise this right, contact the hospital’s Director of Human Resources at 410-871-6837.

If you would like to pursue any of your individual rights regarding your PHI, contact the hospital’s Director of Human Resources at 410-871-6837. You have the right to contact U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) if you have any complaints about how the plan has handled your PHI. You can submit your complaint online, or download a complaint form by visiting cms.hhs.gov/hipaa. Or, you can send your complaint or question to [email protected]. Or, you can call the CMS HIPAA Hotline at 1-866-282-0659.

This notice becomes effective on January 1, 2013.

notes

37 + nOtEs

Questions? Go to the Human Resources link on Carroll Hospital Center’s Intranet or call the Human Resources Department at 410-871-7071.

200 Memorial Avenue Westminster, MD 21157410.848.3000 www.CarrollHospitalCenter.org

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