Laws Affecting Benefits
Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985
If you terminate your employment or reduce your hours of employment, you will usually have the right to temporarily continue your health and dental coverage through CWRU. The remainder of this letter explains your specific legal rights. This law requires that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health and dental coverage (called "COBRA coverage") at group rates in certain qualifying instances where coverage under the plan would otherwise end. If you are an employee of CWRU and are covered by one of the group health and dental plans, you have a right to choose COBRA coverage if you lose your group health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part).
If you are the spouse of an employee covered by one of the university's basic health plans, you have the right to choose COBRA coverage for yourself if you lose group health coverage due to any one of the following four qualifying events:
- The death of your spouse;
- A termination of your spouse's CWRU employment (for reasons other than gross misconduct) or reduction in your spouse's hours of employment that renders him/her ineligible to continue group medical and dental coverage;
- Divorce or legal separation from your spouse; or
- Your spouse becomes entitled to Medicare.
If you are the dependent child of a former CWRU employee and covered by a group health or dental plan sponsored by CWRU, you have the right to choose COBRA coverage for yourself if your group health and dental coverage stops due to any one of the following five qualifying events.
- The death of a parent;
- A termination of your parent's CWRU employment (for reasons other than gross misconduct) or reduction in your parent's hours of employment with CWRU that renders him/her ineligible to continue group medical and dental coverage;
- Parents' divorce or legal separation;
- A parent becomes entitled to Medicare; or
- The dependent child attains the age of 26
If you choose COBRA coverage, CWRU will provide the same coverage which is being provided to all similarly situated employees and family members. Under the law, the employee of a family member has the responsibility to inform Benefits Administration of a divorce, legal separation, or child losing dependent status under one of the plans. The University must internally identify the employee's death, termination of employment, reduction in hours, or Medicare eligibility.
When Benefits Administration is advised that a qualifying event has occurred, Benefits Administration will notify you that you have the right to choose COBRA coverage. Under the law, you have 60 days from the date you would lose coverage due to one of the qualifying events described above to inform Benefits Administration that you want COBRA coverage.
If you do not choose COBRA coverage, your group health insurance coverage will end as of the date of the qualifying event. If you do choose COBRA coverage, the university is required to give you coverage which, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees of family members. The law requires that you be afforded the opportunity to maintain coverage for up to 36 months unless you lost group health coverage because of a termination of employment or reduction in hours. In that case, the required COBRA coverage period is 18 months. If you are disabled at the time of the original qualifying event, you may be eligible for a total of 29 months of COBRA coverage, provided that a determination letter from the Social Security Administration is presented as evidence before the 18-month COBRA coverage period has expired. However, the law also provides that your COBRA coverage may be cut short for any of the following five reasons:
- The university no longer provides group health and dental coverage to any of its employees;
- The premium for your COBRA coverage is not paid (payment must be received no later than 30 days after it is due);
- You become covered under another group health plan as an employee or otherwise;
- You become entitled to Medicare;
- You were divorced from a covered employee and subsequently remarry and are covered under your new spouse's group health plan.
You do not have to show that you are insurable to choose COBRA coverage. You will be responsible for paying both the employer and the employee's premiums to receive this coverage plus two percent (2%) to cover administrative costs. The law also says that, at the end of the 18-month or 36-month coverage period, you must be allowed to enroll in an individual conversion health plan provided by the particular carrier.
This law applies to any of the university health plans beginning on June 1, 1987, under §10002(d) of COBRA as enacted April 7, 1986 (Public Law 99-272, Title X), and as amended. If you have any questions about the law, please contact Case Western Reserve University, Benefits Administration, 224 Crawford Hall, 10900 Euclid Avenue, Cleveland, Ohio 44106-7047. Also if you have changed marital status or you or your spouse have changed addresses, please notify Benefits Administration at the above address.» return to top
HIPAA and Privacy Practices on Protected Health Information
Protected health information (PHI) means any information, transmitted or maintained in any form or medium, which the Plan creates or receives that relates to your physical or mental health, the delivery of health care services to your or payment for health care services and that identifies you or could be used to identify you. We maintain your PHI in records we create of claims submitted to or payments made by the Plan and related information. This Notice applies to all of those records created, received or maintained by the Plan.
The university is permitted to use and disclose your protected health information (PHI) (1) to provide treatment to you, (2) to be paid or request payment for our services, and (3) to conduct health care operations. This section of this Notice discusses each of these types of uses and disclosures of PHI.
- For Treatment. We may use PHI about you in connection with health care treatment or services. We may disclose PHI to doctors, nurses, hospitals, clinics, or other health care providers who are involved in your care. For example, a doctor treating you for a medical condition may need to know the medications which have been prescribed for you, or the services and items that have been provided to you. We may also share PHI about you in order to coordinate health care services and items that you may need.
- For Payment. We may use and disclose PHI about you to process payments for the services and items that you receive from health care providers. For example, we may need to share your health information with a provider to verify the delivery of services or items that you received so that the Plan can pay the provider or reimburse you for the services or items.
- For Health Care Operations. We may use and disclose PHI about you for health care operations. These uses and disclosures are necessary to make sure you receive quality care. For example, we may use PHI to review treatment and services and to evaluate the performance of providers. We may also disclose information to doctors, nurses, hospitals, clinics, and other health care providers, for review and learning purposes. We may remove information that identifies you from PHI used for such purposes so others may use it to study health care and health care delivery without learning the names of the specific individuals.
Listed below are a number of other ways that the Plan is permitted or required to use or disclose PHI. This list is not exhaustive. Therefore, not every use or disclosure in a category is listed.
- Individuals Involved in Your Care or Payment for Your Care. We may release PHI about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition, we may disclose PHI about you to a person or entity assisting in an emergency so that your family can be notified about your condition, status and location.
- As Required By Law. We will disclose PHI about you when required to do so by federal, state, or local law.
- Public Health Risks. We may disclose PHI about you for public health activities, including to prevent or control disease or, when required by law, to notify public authorities concerning cases of abuse or neglect.
- Health Oversight Activities. We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
- Lawsuits and Disputes. If you are involved in a lawsuit or dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
- Law Enforcement. We may release PHI if asked to do so by a law enforcement official as permitted by law.
- Coroners and Medical Examiners. We may release PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
- Research. Under certain circumstances, we may use and disclose PHI about you for research purposes. For example, we might disclose PHI to be used in a research project involving the effectiveness of certain treatment. In some cases, we might disclose PHI for research purposes without your knowledge or approval. However, such disclosures will be made only if approved through a special process. This process evaluates a proposed research project and its use of PHI, trying to balance the research needs with an individual's need for privacy of their PHI.
- To Avert a Serious Threat to Health or Safety. We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
- Military and Veterans. If you are a member of the armed forces, we may release PHI about you as required by military command authorities.
- Health-Related Benefits and Services. We may use and disclose PHI to tell you about health-related benefits or services that may be of interest to you.
- Workers’ Compensation. We may release PHI about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
- Fundraising. We may disclose PHI about you for fundraising purposes. Any such disclosure of PHI will be limited in scope and disclosed only to our business associates or to a charitable organization which is obligated to act for the benefit of CWRU. If you do not want CWRU to contact you about fundraising, you must notify the CWRU Privacy Officer in writing. Further information about disclosures for fundraising purposes may be found in CWRU’s Policies and Procedures, “Fundraising.”
Other uses and disclosures will be made only upon your written authorization. You have the right to revoke such authorization, in writing, except where we have previously taken action in reliance on your prior authorization or if the authorization was a condition to obtaining insurance or health plan coverage and applicable law provides the insurer or health plan with the right to contest a claim under the policy.
When required to do, the Plan will disclose only the minimum amount of PHI necessary to accomplish the intended purpose of a use, disclosure or request for PHI.
Certain provisions of Ohio law may now, or in the future, impose greater restrictions on uses and/or disclosures of PHI or otherwise be more stringent than federal rules protecting the privacy of PHI. If such provisions of Ohio law apply to a use or disclosure of PHI or under other circumstances described in this Notice, CWRU must comply with those provisions.
You have the following rights with respect to your PHI:
- Right to Inspect and Copy. You have the right to inspect and copy your PHI maintained by the Plan. Generally, this information includes health care and billing records. You do not have a right of access to (1) psychotherapy notes; (2) information prepared in anticipation of or for use in, a civil, criminal, or administrative action; and (3) PHI maintained by the Plan that is (a) subject to the Clinical Laboratory Improvements Amendments (“CLIA”) of 1988, 42 U.S.C. 263a, if access to the individual would be prohibited by law, or (b) exempt from CLIA pursuant to 42 CFR 493.3(a)(2). Under certain circumstances, you also do not have a right of access to information created or obtained in the course of research involving treatment or received from someone other than a health care provider under a promise of confidentiality.
- To inspect and copy PHI maintained by the Plan, you must submit your request in writing to CWRU’s Privacy Officer. We may charge a fee for the costs of copying, mailing or other supplies associated with you request. We may deny your request to inspect and copy your PHI for the reasons set forth above or under certain other limited circumstances. If you are denied access to PHI other than for a reason stated above, you will receive a written denial. You may request that the denial be reviewed. Thereafter, a licensed health care provider chosen by CWRU will review your request and the denial. The person conducting the review will not be the person who originally denied your request. We will comply with the outcome of the review.
- Right to Request Amendment. You may ask us to amend the PHI we have about you. You have the right to request an amendment for so long as the information is kept by or for the Plan. To request an amendment to your PHI, your request must be made in writing and submitted to CWRU’s Privacy Officer. In addition, you must provide a reason that supports your request. We will generally make a decision regarding your request for amendment no later than 60 days after receipt of your request. However, if we are unable to act on the request within this time, we may extend the time for 30 more days, but we will provide you with a written notice of the reason for the delay and the approximate time for completion. If we deny your requested amendment, we will provide you with a written denial.
- We have the right to deny your request for an amendment if it is not in writing or does not include a reason to support the request. We are not required to agree to your request if you ask us to amend PHI that: was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the PHI kept by or for the Plan; is not part of the PHI which you would be permitted to inspect and copy; or is already accurate and complete.
- Right to an Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of certain disclosures of PHI we have made about you. We do not have to list certain disclosures such those made for the purposes of treatment, payment, or healthcare operations, pursuant to a prior authorization by you or for certain law enforcement purposes.
- To request this list or accounting of such disclosures, your request must be submitted in writing to CWRU’s Privacy Officer. Your request must also state a time period, which may not be longer than six years and may not include dates before April 14, 2003. Your request should also specify the format of the list you prefer (i.e. on paper or electronically). The first list you request within a twelve month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
- Right to Request Restriction of Uses and Disclosures. You have the right to request that we restrict the uses and disclosures of PHI about you to carry out treatment, payment or health care operations and/or to individuals involved in your care. We cannot restrict disclosures required by law or requested by the federal government to determine if we are meeting our privacy protection obligations. We are not required to agree to your request; however, if we do agree, we will comply with your request unless the information is needed to provide you emergency health care treatment. To request restrictions, you must make your request in writing to CWRU’s Privacy Officer. Your request must specify (1) what PHI you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply (i.e., disclosures to your spouse). We may terminate our agreement to the restriction if you orally agree to the termination and it is documented, you request the termination in writing, or we inform you that we are terminating our agreement with respect to any information created or received after receipt of our notice.
- Right to Request Confidential Communications. You also have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to CWRU’s Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. You request must specify how or where you wish to be contacted.
- Right to Receive Notice Electronically. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. To obtain a paper copy of this notice, please write to or call CWRU’s Privacy Officer.
The university reserves the right to change our privacy practices that are described in this Notice. We reserve the right to make the revised or changed privacy practices applicable to PHI we already have about you as well as any information we receive in the future. Prior to a material change to the uses or disclosures, your rights, our legal duties, or other privacy practices stated in this Notice, we will promptly revise the Notice. The Notice will contain the effective date on the first page.
If you believe your privacy rights have been violated, you may file a complaint with CWRU or with the Secretary of the Department of Health and Human Services. To file a complaint with CWRU, write to CWRU’s Privacy Officer, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-7048. All complaints must be in writing. You will not be penalized or retaliated against for filing a complaint.
Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose PHI about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose PHI about you for the reasons covered by your written authorization. You understand that we are unable to retract any disclosures we have already made with your authorization, and that we are required to retain records of the Plan relating to claims, coordination of benefits, payments by the Plan and related matters.» return to top
Women’s Health and Cancer Rights Act of 1998
Also known as “Janet’s Law,” the WHCRA requires health care benefit plans to provide certain coverage following a mastectomy. The law also requires annual notification to all plan participants and their covered beneficiaries. CWRU group health plans provide coverage for mastectomies. As part of this coverage, the plans also cover procedures necessary to effect reconstruction of the breast on which the mastectomy was performed, as well as the cost of prostheses (implants, special bras, etc.). Coverage is also provided for physical complications of all stages of mastectomy, including lymphedemas, as recommended by the attending physician of any patient receiving plan benefits in connection with the mastectomy. Health plans also cover any necessary surgery and reconstruction of the breast on which a mastectomy was performed in order to produce a symmetrical appearance. This coverage is subject to the same deductibles and co-insurance that apply to mastectomies under current terms. Please refer to your particular benefit plan booklet regarding deductible and co-insurance requirements for mastectomies.