**CONTINUATION COVERAGE RIGHTS UNDER COBRA**
Federal law requires certain employers sponsoring group health plan coverage to offer their employees
(and his or her enrolled family members) the opportunity to elect to extend health coverage should a loss
of plan coverage occur due to a qualifying event. You are receiving this notice because you have either
(1) recently been hired by Meritus Health, Inc., and are enrolled in the Meritus Health, Inc. Group Health
Plan or (2) you recently added a newly eligible dependent to your plan. This notice contains important
information about the right you and your covered dependents have under COBRA continuation coverage.
Both you (the employee) and your enrolled dependents (if applicable) should read this notice
carefully and keep it with your records.
Introduction
You are receiving this notice because you have recently become covered under Meritus Health, Inc. (the
Plan). This notice contains important information about your right to COBRA continuation coverage, which
is a temporary extension of coverage under the Plan. The right to COBRA continuation coverage was
created by a federal law, Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA
continuation coverage can become available to you and to other members of your family who are covered
under the Plan when you would otherwise lose your group health coverage. This notice generally
explains COBRA continuation coverage, when it may become available to you and your family,
and what you need to do to protect the right to receive it. This notice gives only a summary of your
COBRA continuation coverage rights. For more information about your rights and obligations under the
Plan and under federal law, you should either review the Plan's Summary Plan Description or get a copy
of the Plan Document from the Plan Administrator.
The Plan Administrator is:
Meritus Health, Inc.
11116 MEDICAL CAMPUS ROAD
HAGERSTOWN, MD 21742
COBRA Continuation Coverage
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end
because of a life event known as a "qualifying event." Specific qualifying events are listed later in the
notice. COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." A
qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event.
Depending on the type of qualifying event, employees, spouses of employees, and dependent children of
employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA
continuation coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan
because one of the following qualifying events happens:
(1) Your hours of employment are reduced; or
(2) Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the
Plan because any of the following qualifying events happens:
(1) Your spouse dies;
(2) Your spouse's hours of employment are reduced;
(3) Your spouse's employment ends for any reason other than his or her gross misconduct;
(4) Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or
(5) You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because
any of the following qualifying events happens:
(1) The parent-employee dies;
(2) The parent-employee's hours of employment are reduced;
(3) The parent-employee's employment ends for any reason other than his or her gross misconduct;
(4) The parent-employee becomes enrolled in Medicare (Part A, Part B, or both);
(5) The parents become divorced or legally separated; or
(6) The child stops being eligible for coverage under the plan as a "dependent child."
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying
event. If a proceeding in bankruptcy is filed with respect to Meritus Health, Inc. and that bankruptcy
results in the loss of coverage of any retired employee covered under the Plan, the retired employee is a
qualified beneficiary with respect to the bankruptcy. The retired employee's spouse, surviving spouse,
and dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their
coverage under the Plan.
The plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has
been notified that a qualifying event has occurred. When the qualifying event is the end of employment or
reduction of hours of employment, death of the employee, or enrollment of the employee in Medicare
(Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event. In
addition, if the Plan provides retiree health coverage, then commencement of a proceeding in a
bankruptcy with respect to the employer is also a qualifying event where the employer must notify the
Plan Administrator of the qualifying event.
For the other qualifying events (divorce or legal separation of the employee and spouse or a
dependent child losing eligibility for coverage as a dependent child), you must notify the Plan
Administrator. The Plan requires you to notify the Plan Administrator, in writing, within 60 days
after the qualifying event occurs.
You must send this notice to:
PayFlex Systems USA, Inc.
BENEFITS BILLING DEPARTMENT
P.O. BOX 2239
OMAHA, NE 68103-2239
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation
coverage will be offered to each of the qualified beneficiaries. For each qualified beneficiary who elects
COBRA continuation coverage, COBRA continuation coverage will begin either (1) on the date of the
qualifying event or (2) on the date that Plan coverage would otherwise have been lost, depending on the
nature of the Plan.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the
death of the employee, enrollment of the employee in Medicare (Part A, Part B, or both), your divorce or
legal separation, or a dependent child losing eligibility as a dependent child, COBRA continuation
coverage lasts for up to 36 months.
When the qualifying event is the end of employment or reduction of the employee's hours of employment,
COBRA continuation coverage lasts for up to 18 months. There are two ways in which this 18-month
period of COBRA continuation coverage can be extended.
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security
Administration to be disabled at any time during the first 60 days of COBRA continuation
coverage and you notify the Plan Administrator in a timely fashion, you and your entire family can
receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29
months. The disability would have to have started at some time before the 60th day of COBRA
continuation coverage and must last at least until the end of the 18-month period of continuation
coverage. You must notify PayFlex of that fact within 60 days of the later of 1) the SSA's
determination of disability (the date of the SSA award letter); 2) the date of your qualifying event;
3) the date of your loss of coverage; or 4) the date you were notified of the requirement
(the date of your qualifying event letter). The notification must also be provided before the end of
the first 18 months of continuation coverage. Also, you are required to notify the Plan
Administrator of any change in your disabled status. This notice should be sent to:
PayFlex Systems USA, Inc.
BENEFITS BILLING DEPARTMENT
P.O. BOX 2239
OMAHA, NE 68103-2239
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving COBRA continuation coverage, the
spouse and dependent children in your family can get additional months of COBRA continuation
coverage, up to a maximum of 36 months. This extension is available to the spouse and dependent
children if the former employee dies, enrolls in Medicare (Part A, Part B, or both), or gets divorced or
legally separated. These events can be a second qualifying event only if they would have caused the
qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. The
extension is also available to a dependent child when that child stops being eligible under the Plan as a
dependent child. In all of these cases, you must make sure that the Plan Administrator is
notified of the second qualifying event within 60 days of the second qualifying event. This notice
must be sent to:
PayFlex Systems USA, Inc.
BENEFITS BILLING DEPARTMENT
P.O. BOX 2239
OMAHA, NE 68103-2239
If You Have Questions
If you have questions about your COBRA continuation coverage, you should contact PayFlex Systems
USA, Inc. or you may contact the nearest Regional or District Office of the U.S Department of Labor's
Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and
District EBSA Offices are available through EBSA's website at http://www.dol.gov/ebsa.
Keep Your Plan Informed of Address Changes
In order to protect your family's rights, you should keep the Plan Administrator informed of any
changes in the addresses of family members. You should also keep a copy, for your records, of any
notices you send to the Plan Administrator.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes some provisions that
may affect decisions you make about your participation in the Group Health Plan under the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA). These provisions are as follows:
1. Under COBRA, if the qualifying event is a termination or reduction in hours of employment, affected
qualified beneficiaries are entitled to continue coverage for up to 18 months after the qualifying event,
subject to various requirements. Before HIPAA, this 18-month period could be extended for up to 11
months (for a total COBRA coverage period of up to 29 months from the initial qualifying event) if an
individual was determined by the Social Security Administration, under the Social Security Act, to have
been disabled at the time of the qualifying event and if the plan administrator was notified of that disability
determination within 60 days of the determination and before the end of the original 18-month period.
Under HIPAA, if a qualified beneficiary is determined by the Social Security Administration to be disabled
under the Social Security Act at any time during the first 60 days of COBRA coverage, the 11-month
extension is available to all individuals who are qualified beneficiaries due to the termination or reduction
in hours of employment. The disabled individual can be a covered employee or any other qualified
beneficiary. However, to be eligible for the 11- month extension, affected individuals must still comply with
the notification requirements in a timely fashion.
2. A child that is born to or placed for adoption with the covered employee during a period of COBRA
coverage will be eligible to become a qualified beneficiary. In accordance with the terms of the employer's
group health plan(s) and the requirements of Federal law, these qualified beneficiaries can be added to
COBRA coverage upon proper notification to the Plan Administrator of the birth or adoption.
3. HIPAA restricts the extent to which group health plans may impose pre-existing condition limitations.
4. If you were covered by a group health plan(s) prior to your employment with us, your previous
employer their insurance carrier should have provided you with a Certificate of Creditable Coverage, a
form required by the HIPAA law that describes the health coverage you and your dependents, if any,
have or had, and the dates you were covered. IF YOU HAVE NOT RECEIVED A CERTIFICATE OF
CREDITABLE COVERAGE AND ARE ENTITLED TO ONE, PLEASE CONTACT YOUR FORMER
EMPLOYER. Once you deliver the Certificate of Creditable Coverage to your new insurance carrier, you
are exempt from any pre-existing condition exclusions in our group health plan(s), provided you had
twelve months of creditable coverage (eighteen months if a late enrollment) and have not had more than
a sixty-three day gap in coverage.
5. Under COBRA, your right to continuation coverage terminates if you become covered by another
employer's group health plan that does not limit or exclude coverage for your pre-existing conditions. If
you become covered by another group health plan and that plan contains a pre-existing condition
limitation that affects you, your COBRA continuation coverage cannot be immediately terminated.
However, if the other plan's pre-existing condition rule does not apply to you by reason of HIPAA's
restrictions on pre-existing condition clauses, the employer's group health plan(s) may terminate your
COBRA coverage.
If you have any questions about COBRA, or if you have changed marital status, or you or your spouse
have changed addresses, please contact PayFlex Systems USA, Inc. at (888) 678-7835.
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH
INFORMATION REQUIRED NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Effective Date of Notice: November 1, 2011
The Meritus Health Employees' Health Benefit Plan (the "Plan") is required by law to take
reasonable steps to ensure the privacy of your personally identifiable health information and to
inform you about: · the Plan's uses and disclosures of Protected Health Information (PHI);
 your privacy rights with respect to your PHI;
 the Plan's duties with respect to your PHI;
 your right to file a complaint with the Plan and to the Secretary of the U.S. Department of
Health and Human Services; and
 the person or office to contact for further information about the Plan's privacy practices.
The term "Protected Health Information" (PHI) includes all individually identifiable health
information transmitted or maintained by the Plan, regardless of form (oral, written, electronic).
SECTION 1. NOTICE OF PHI USES AND DISCLOSURES
Required PHI Uses and Disclosures
Upon your request, the Plan is required to give you access to certain PHI in order to inspect and
copy it.
Use and disclosure of your PHI may be required by the Secretary of the Department of Health
and Human Services to investigate or determine the Plan's compliance with the privacy
regulations.
Uses and disclosures to carry out treatment, payment and health care operations
The Plan and its business associates will use PHI without your consent, authorization or
opportunity to agree or object to carry out treatment, payment and health care operations. The
Plan also will disclose PHI to the Plan Sponsor Meritus Health for purposes related to treatment,
payment and health care operations. The Plan Sponsor has amended its plan documents to
protect your PHI as required by federal law.
Treatment is the provision, coordination or management of health care and related services. It
also includes but is not limited to consultations and referrals between one or more of your
providers.
For example, the Plan may disclose to a treating orthodontist the name of your treating dentist so
that the orthodontist may ask for your dental X-rays from the treating dentist. Payment includes
but is not limited to action to make coverage determinations and payment
(including billing, claims management, subrogation, plan reimbursement, reviews for medical
necessity and appropriateness of care and utilization review and preauthorizations).
For example, the Plan may tell a doctor whether you are eligible for coverage or what percentage
of the bill will be paid by the Plan.
Health care operations include but are not limited to quality assessment and improvement,
reviewing competence or qualifications of health care professionals, underwriting, premium
rating and other insurance activities relating to creating or renewing insurance contracts. It also
includes disease management, case management, conducting or arranging for medical review,
legal services and auditing functions including fraud and abuse compliance programs, business
planning and development, business management and general administrative activities.
For example, the Plan may use information about your claims to refer you to a disease
management program, project future benefit costs or audit the accuracy of its claims processing
functions.
Uses and disclosures that require your written authorization
Your written authorization generally will be obtained before the Plan will use or disclose
psychotherapy notes about you from your psychotherapist. Psychotherapy notes are separately
filed notes about your conversations with your mental health professional during a counseling
session. They do not include summary information about your mental health treatment. The Plan
may use and disclose such notes when needed by the Plan to defend against litigation filed by
you.
Uses and disclosures that require that you be given an opportunity to agree or disagree prior to
the use or release
Disclosure of your PHI to family members, other relatives and your close personal friends is
allowed
if:
 the information is directly relevant to the family or friend's involvement with your care or
payment for that care; and
 you have either agreed to the disclosure or have been given an opportunity to object and
have not objected.
Uses and disclosures for which consent, authorization or opportunity to object is not required
Use and disclosure of your PHI is allowed without your consent, authorization or request under
the following circumstances:
(1) When require by law.
(2) When permitted for purpose of public health activities, including when necessary to report
product defects, to permit product recalls and to conduct post-marketing surveillance. PHI may
also be used or disclosed if you have been exposed to a communicable disease or are at risk of
spreading a disease or condition, if authorized by law.
(3) When authorized by law to report information about abuse, neglect or domestic violence to
public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or
domestic violence. In such case, the Plan will promptly inform you that such a disclosure has
been or will be made unless that notice would cause a risk of serious harm. For the purpose of
reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has
been or will be made. Disclosure may generally be made to the minor's parents or other
representatives although there may be circumstances under federal or state law when the parents
or other representatives may not be given access to the minor's PHI.
(4) The Plan may disclose your PHI to a public health oversight agency for oversight activities
authorized by law. This includes uses or disclosures in civil, administrative or criminal
investigations; inspections; licensure or disciplinary actions (for example, to investigate
complaints against providers); and other activities necessary for appropriate oversight of
government benefit programs (for example, to investigate Medicare or Medicaid fraud).
(5) The Plan may disclose your PHI when required for judicial or administrative proceedings.
For example, your PHI may be disclosed in response to a subpoena or discovery request
provided certain conditions are met. One of those conditions is that satisfactory assurances must
be given to the Plan that the requesting party has made a good faith attempt to provide written
notice to you, and the notice provided sufficient information about the proceeding to permit you
to raise an objection and no objections were raised or were resolved in favor of disclosure by the
court or tribunal.
(6) When required for law enforcement purposes (for example, to report certain types of
wounds).
(7) For law enforcement purposes, including for the purpose of identifying or locating a suspect,
fugitive, material witness or missing person. Also, when disclosing information about an
individual who is or is suspected to be a victim of a crime but only if the individual agrees to the
disclosure or the covered entity is unable to obtain the individual's agreement because of
emergency circumstances. Furthermore, the law enforcement official must represent that the
information is not intended to be used against the individual, the immediate law enforcement
activity would be materially and adversely affected by waiting to obtain the individual's
agreement and disclosure is in the best interest of the individual as determined by the exercise of
the Plan's best judgment.
(8) When required to be given to a coroner or medical examiner for the purpose of identifying a
deceased person, determining a cause of death or other duties as authorized by law. Also,
disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry
out their duties with respect to the decendent.
(9) The Plan may use or disclose PHI for research, subject to conditions.
(10) When consistent with applicable law and standards of ethical conduct if the Plan, in good
faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent
threat to the health or safety of a person or the public and the disclosure is to a person reasonably
able to prevent or lessen the threat, including the target of the threat.
(11) When authorized by and to the extent necessary to comply with workers' compensation or
other similar programs established by law.
Except as otherwise indicated in this notice, uses and disclosures will be made only with your
written authorization subject to your right to revoke such authorization.
SECTION 2. RIGHT OF INDIVIDUALS
Right to Request Restrictions on PHI Uses and Disclosures
You may request the Plan to restrict uses and disclosures of your PHI to carry out treatment,
payment or health care operations, or to restrict uses and disclosures to family members,
relatives, friends or other persons identified by you who are involved in your care or payment for
your care. However, the Plan is not required to agree to your request.
The Plan will accommodate reasonable requests to receive communications of PHI by alternative
means or at alternative locations.
You or your personal representative will be required to complete a form to request restrictions on
uses and disclosures of your PHI.
Such requests should be made to:
Meritus Health - Benefits Specialist
Human Resources Department
11116 Medical Campus Road
Hagerstown, MD 21742
Right to Inspect and Copy PHI
You have a right to inspect and obtain a copy of your PHI contained in a "designated record set,"
for as long as the Plan maintains the PHI.
"Protected Health Information" (PHI) includes all individually identifiable health information
transmitted or maintained by the Plan, regardless of form.
"Designated Record Set" includes the medical records and billing records about individuals
maintained by or for a covered health care provider; enrollment, payment, billing, claims
adjudication and case or medical management record systems maintained by or for a health plan;
or other information used in whole or in part by or for the covered entity to make decisions about
individuals. Information used for quality control or peer review analyses and not used to make
decisions about individuals is not in the designated record set.
The requested information will be provided within 30 days if the information is maintained on
site or within 60 days if the information is maintained offsite. A single 30-day extension is
allowed if the Plan is unable to comply with the deadline.
You or your personal representative will be required to complete a form to request access to the
PHI in your designated record set. Requests for access to PHI should be made to:
Meritus Health - Benefits Specialist
Human Resources Department
11116 Medical Campus Road
Hagerstown, MD 21742
If access is denied, you or your personal representative will be provided with a written denial
setting forth the basis for the denial, a description of how you may exercise those review rights
and a description of how you may complain to the Secretary of the U.S. Department of Health
and Human Services.
Right to Amend PHI
You have the right to request the Plan to amend your PHI or a record about you in a designated
record set for as long as the PHI is maintained in the designated record set.
The Plan has 60 days after the request is made to act on the request. A single 30-day extension is
allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or
part, the Plan must provide you with a written denial that explains the basis for the denial. You or
your personal representative may then submit a written statement disagreeing with the denial and
have that statement included with any future disclosure of your PHI.
Requests for amendment of PHI in a designated record set should be made to:
Meritus Health - Benefits Specialist
Human Resources Department
11116 Medical Campus Road
Hagerstown, MD 21742
You or your personal representative will be required to complete a form to request amendment of
the PHI in your designated record set.
The Right to Receive an Accounting of PHI Disclosures
At your request, the Plan will also provide you with an accounting of disclosures by the Plan of
your PHI during the six years prior to the date of your requests. However, such accounting need
not include PHI disclosures made: (1) to carry out treatment, payment or health care operations;
(2) to individuals about their own PHI; or (3) prior to the compliance date.
If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the
individual is given a written statement of the reasons for the delay and the date by which the
accounting will be provided.
If you request more than one accounting within a 12-month period, the Plan will charge a
reasonable, cost-based fee for each subsequent accounting.
The Right to Receive a Paper Copy of This Notice Upon Request
To obtain a paper copy of this Notice contact:
Meritus Health - Benefits Specialist
Human Resources Department
11116 Medical Campus Road
Hagerstown, MD 21742
A Note About Personal Representatives
You may exercise your rights through a personal representative. Your personal representative
will be required to produce evidence of his/her authority to act on your behalf before that person
will be given access to your PHI or allowed to take any action for you. Proof of such authority
may take one of the following forms:
 A power of attorney for health care purposes, notarized by a notary public;
 A court order of appointment of the person as the conservator or guardian of the
individual; or
 An individual who is the parent of a minor child. The Plan retains discretion to deny
access to your PHI to a personal representative to provide protection to those vulnerable
people who depend on others to exercise their rights under these rules and who may be
subject to abuse or neglect. This also applies to personal representatives of minors.
SECTION 3. THE PLAN'S DUTIES
The Plan is required by law to maintain the privacy of PHI and to provide individuals
(participants and beneficiaries) with notice of its legal duties and privacy practices.
This notice is effective beginning May 18, 2009 and the Plan is required to comply with the
terms of this notice. However, the Plan reserves the right to change its privacy practices and to
apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy
practice is changed, a revised version of this notice will be provided to all participants and
beneficiaries for whom the Plan still maintains PHI. This notice will be sent via internal
communications (MOX) to all participants employed by Meritus Health and mailed via
US Mail to all non-employed participants.
A revised version of this notice will be distributed within 60 days of the effective date of any
material change to the uses or disclosures, the individual's rights, the duties of the Plan or other
privacy practices stated in this notice.
Minimum Necessary Standard
When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will
make reasonable efforts not to use, disclose or request more than the minimum amount of PHI
necessary to accomplish the intended purpose of the use, disclosure or request, taking into
consideration practical and technological limitations.
However, the minimum necessary standard will not apply in the following situations:
 Disclosures to or requests by a health care provider for treatment;
 Uses or disclosures made to the individual;
 Disclosures made to the Secretary of the U.S. Department of Health and Human Services;
 Uses or disclosures that are required by law; and
 Uses or disclosures that are required for the Plan's compliance with legal regulations.
This notice does not apply to information that has been de-identified. De-identified information
is information that does not identify an individual and with respect to which there is not
reasonable basis to believe that the information can be used to identify an individual is not
individually identifiable health information.
In addition, the Plan may use or disclose "summary health information" to the plan sponsor for
obtaining premium bids or modifying, amending or terminating the group health plan, which
summarizes the claims history, claims expenses or type of claims experienced by individuals for
whom a plan sponsor has provided health benefits under a group health plan; and from which
identifying information has been deleted in accordance with HIPAA.
SECTION 4. YOUR RIGHT TO FILE A COMPLAINT WITH THE PLAN OR THE HHS
SECRETARY
If you believe that your privacy rights have been violated, you may complain to the Plan in care
of:
Meritus Health - Benefits Specialist
Human Resources Department
11116 Medical Campus Road
Hagerstown, MD 21742
You may file a complaint with the Secretary of the U.S. Department of Health and Human
Services, Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, D.C.
20201.
The Plan will not retaliate against you for filing a complaint.
SECTION 5. WHOM TO CONTACT AT THE PLAN FOR MORE INFORMATION
If you have any questions regarding this notice or the subjects addressed in it, you may contact:
Meritus Health - Benefits Specialist
Human Resources Department
11116 Medical Campus Road
Hagerstown, MD 21742
CONCLUSION
PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health
Insurance Portability and Accountability Act). You may find these rules at Code of Federal
Regulations Parts 160 and 164. This notice attempts to summarize the regulations. The
regulations will supersede any discrepancy between the information in this notice and the
regulations.
12/1/2013