Retiree-Only Health Reimbursement Arrangement Summary Plan Description

HRA expenses that are eligible for reimbursement are as follows:

• Medical, prescription drug, dental, and vision premiums (pre tax deductions from a paycheck are not eligible for reimbursement)
• Medicare Part B premiums
• Higher premiums you may pay above the standard premiums for Medicare Part B or Medicare Part D due to your higher income; this is called an Income-Related Monthly Adjustment Amount (IRMAA) by Medicare
• Qualifying out-of-pocket medical, dental, and vision expenses such as deductibles, copays and your share of coinsurance, excluding prescription drugs.

Health care expenses that are not eligible for reimbursement are as follows:

• Prescription drug out of pocket costs (e.g., deductible, copays)
• Long-term care premiums and out-of-pocket expenses

You and Via Benefits work together to evaluate the options and select the plan that is right for you

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You enroll in a plan through Via Benefits October 15 – December 7, to be effective the following January 1

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After you enroll, RIT credits your HRA the first business day following January 1

You pay your premium directly to your insurance carrier and pay your out-of-pocket costs (e.g., copays)

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You submit your claim to Via Benefits*

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Via Benefits reimburses you from your HRA account

* Some insurance companies send proof of your premium payment to Via Benefits so you can be automatically reimbursed for your premium without submitting a manual claim to Via Benefits for reimbursement. Ask your Benefit Advisor about Via Benefits’ “Automatic Reimbursement.” If automatic reimbursement is not available with your insurance company, ask the Benefit Advisor about the Recurring Premium Reimbursement process, which only requires you to complete one form at the beginning of each year.

Claims are required to be filed no later than June 30 of the year following the year the expense was incurred. Claims received after this deadline will not be reimbursed.

If you did not elect automatic or recurring reimbursement for your premium payments, you must complete a reimbursement form and submit online, mail or fax it to Via Benefits along with a copy of your insurance premium bill. To be reimbursed for qualifying out-of-pocket expenses, you need to submit an “explanation of benefits” or “EOB,” or, if no EOB is provided, a written statement from the service provider. The written statement from the service provider must contain the following: (a) the name of the patient, (b) the date service or treatment was provided, (c) a description of the service or treatment, (d) the amount incurred and (e) name of provider. You can obtain a reimbursement form from Via Benefits. Your claim is deemed filed when it is received by Via Benefits.

If your claim for reimbursement is approved, you will be provided reimbursement as soon as reasonably possible following the determination. Claims are paid in the order in which they are received by Via Benefits.

Via Benefits shall determine the method or mode of reimbursement payments, including whether by direct deposit, written check or otherwise.

Any HRA payments that are unclaimed (e.g., uncashed benefit checks or unclaimed electronic transfers) shall automatically forfeit twelve months after the check was mailed or the payment was otherwise attempted.

In the event that you reach the catastrophic coverage level of Medicare Part D for an applicable year, as defined annually by the Federal Centers for Medicare and Medicaid Services (CMS), RIT provides special Catastrophic Prescription Drug Coverage reimbursement under this Plan.

A Catastrophic Prescription Drug Coverage reimbursement can be obtained by contacting Via Benefits and requesting a claim form for this purpose.

Once you reach the Catastrophic Prescription Drug Coverage reimbursement level, RIT will make a one- time contribution to a separate HRA Account that can only be used by the person who reached this level for claims incurred during that calendar year. There is a maximum per person amount determined by RIT annually, as reflected in the Annual HRA Amounts section at the end of this summary. The one-time amount is allocated to your separate Catastrophic Rx HRA Account, after which you can file eligible claims for reimbursement of your qualifying prescription drug expenses. The deadline for filing claims is March 31 of the following year. Unused amounts in this account do not roll over to a future year. Other HRA Account rules discussed in this summary continue to apply.

If the retiree or retirement-eligible LTD recipient dies with no surviving spouse/partner/child, the deceased retiree’s estate or representatives may submit claims for eligible medical expenses incurred by the retiree before his or her death. Claims must be submitted within one year following his or her death. After one year, any remaining account balance would be forfeited.

If the retiree or retirement-eligible LTD recipient dies and is survived by an eligible spouse or partner who is a Participant, the joint HRA Account shall continue and the surviving Participant can continue to submit eligible medical expenses for reimbursement. If there is an eligible surviving child, the child can continue to submit eligible medical expenses for reimbursement. The surviving spouse or partner will continue to receive his or her own annual HRA credits, unless he or she subsequently remarries/re-partners. The surviving child will continue to
receive his or her own HRA credits, unless he or she reaches the age limit of the plan or is deemed no longer disabled. The deceased retiree’s estate or representatives may submit claims for eligible medical expenses incurred by the retiree before his or her death. Claims must be submitted within one year following his or her death. If the surviving spouse elects and pays for COBRA continuation coverage, as described in the COBRA section of this summary, then both the retiree’s and spouse’s annual HRA credits would continue to be provided during the COBRA continuation period.

If the retiree or retirement-eligible LTD recipient dies and is survived by an eligible pre-Medicare spouse/partner/child, the survivor would be able to participate in this plan when Medicare-eligible, provided they are considered an eligible dependent as outlined above. The deceased retiree’s or retirement-eligible LTD recipient’s remaining HRA balance would be available to the spouse/partner when the spouse/partner becomes eligible for this plan; the balance would not be available for an eligible child.

If an employee who is retirement-eligible dies, the surviving spouse/partner/child would be eligible to participate in this plan when Medicare-eligible, provided they are considered an eligible dependent as outlined earlier in this summary. If the spouse/partner/child is Medicare-eligible when the employee dies, the survivor would be eligible to participate in this plan provided the survivor enrolls in Medicare and medical coverage through Via Benefits. Your survivor would receive a prorated HRA contribution in the year you die, based on when they enroll in coverage through Via Benefits.

If the spouse or partner dies before the retiree, the joint HRA Account shall continue and the retiree can continue to submit eligible medical expenses for reimbursement. The retiree will continue to receive his or her own annual HRA credits. The deceased spouse/partner’s estate or representatives may submit claims for eligible medical expenses incurred by the spouse/partner before his or her death. Claims must be submitted within one year following his or her death.

If the spouse or partner dies after the retiree, the deceased spouse/partner’s estate or representatives may submit claims for eligible medical expenses incurred by the spouse/partner before his or her death. Claims must be submitted within one year following his or her death. After one year, any remaining account balance would be forfeited.

• the date you cease to be a retiree for any reason;
• the date you or your spouse/partner who is covered by this plan are rehired by RIT as an active employee; however, if you or your covered family member is hired by RIT as an employee in an adjunct position or in a regular full-time or part-time employee position that is expected to last less than six months, participation in this plan will be suspended until such time as the individual is no longer an
• employee of RIT. Suspension of participation means that you and your eligible family members will not have access to reimbursements from the plan for claims incurred during the period of employment at RIT, but any remaining account balance will remain available for claims once employment has ended (subject to the terms of the Plan); no additional benefit credits will be added to your account while you are an active RIT employee, but will be added to your account when you are no longer an RIT employee; if you were working for RIT as an adjunct or for less than 6 months, this annual amount will not be prorated, but will be prorated in all other cases;
• the date you cease to be eligible for Medicare (unless you remain eligible under another provision of the Plan);
• the date you no longer have medical coverage through Via Benefits;
• your date of death;
• the effective date of any amendment terminating your eligibility under the Plan; or
• the date the Plan is terminated.

• the date you cease to be an LTD recipient for any reason; however, if you had met the eligibility requirements for retirement from RIT prior to the date you became an LTD recipient, then upon the termination of your LTD recipient status, you will become a retiree;
• two years from the LTD effective date if your LTD effective date is January 1, 2019 or after; if were eligible to retire on your LTD effective date, you will become a retiree;
• the date you or your spouse/partner who is covered by this plan are rehired by RIT as an active employee; however, if you or your covered family member is hired by RIT as an employee in an adjunct position or in a regular full-time or part-time position that is expected to last less than six months, participation in this plan will be suspended until such time as the individual is no longer an employee of RIT. Suspension of participation means that you and your eligible family members will not have access to reimbursements from the plan for claims incurred during the period of employment at RIT, but any remaining account balance will remain available for claims once employment has ended (subject to the terms of the Plan); no additional benefit credits will be added to your account while you or your family member are an active RIT employee, but will be added to your account when you are no longer an RIT employee; if you were working for RIT as an adjunct or for less than 6 months, this annual amount will not be prorated, but will be prorated in all other cases;
• the date you cease to be eligible for Medicare (unless you remain eligible under another provision of the Plan);
• the date you no longer have medical coverage through Via Benefits;
• your date of death;
• the effective date of any amendment terminating your eligibility under the Plan; or
• the date the Plan is terminated.

• the date you cease to be an eligible dependent for any reason;
• the date you cease to be eligible for Medicare (unless you remain eligible under another provisions of the Plan);
• the date you become divorced from the retiree, if you are the spouse;
• the date the retiree completes and files with RIT Human Resources a Statement of Termination of Domestic Partnership, if you are the domestic partner;
• the date you reach the age limit of the plan, if you are a child;
• the date you, if you are the spouse or partner, or the retiree are hired by RIT as an active employee; however, if you or your covered family member is hired by RIT as an employee in an adjunct position or in a regular full-time or part-time position that is expected to last less than six months, participation in this plan will be suspended until such time as the individual is no longer an employee of RIT. Suspension of participation means that you and your eligible family members will not have access to reimbursements from the plan for claims incurred during the period of employment at RIT, but any remaining account balance will remain available for claims once employment has ended (subject to the terms of the Plan); no additional benefit credits will be added to your account while you or your family member are an active RIT employee, but will be added to your account when you are no longer an RIT employee; if you were working for RIT as an adjunct or for less than 6 months, this annual amount will not be prorated, but will be prorated in all other cases;
• the date the LTD recipient is no longer an LTD recipient, unless he or she then becomes a retiree under this Plan;
• the date the LTD recipient loses eligibility, unless he or she then becomes a retiree under this Plan;
• the date you no longer have medical coverage through Via Benefits;
• your date of death;
• the effective date of any amendment terminating your eligibility under the Plan; or
• the date the Plan is terminated.

Although RIT expects to maintain the Plan indefinitely, it has the right to modify or terminate it at any time for any reason, including the right to change the classes of persons eligible for participation, and to reduce or eliminate the amounts credited to HRA accounts in the future.

Only medical, dental and vision care expenses that have not been or will not be fully reimbursed by any other source may be eligible medical expenses (to the extent all other conditions for eligible medical expenses have been satisfied). You must first submit any claims for medical expenses to the other plan or plans before submitting the remaining expenses to this Plan for reimbursement.

If you are also a participant in a health flexible spending account sponsored by an employer, the expenses covered both by this Plan and the health flexible spending account must be submitted first to the health flexible spending account.

Benefit credits allocated to a Participant’s HRA Account are not taxable. Reimbursements of eligible Expenses from an HRA Account are not taxable unless the claim was on behalf of an eligible domestic partner of a retiree. In such cases, RIT will provide Form 1099 to the retiree reflecting the domestic partner’s benefit as taxable
income for tax reporting purposes.

From time to time, overpayments may occur in the administration of the Plan. This includes any payment of Plan benefits to which the Participant was not entitled under the terms of the Plan. In the event of an overpayment, immediate repayment shall be required. Current or future Plan benefits may be reduced, in whole or in part, at any time to recover an overpayment. If deemed necessary, the Plan may pursue legal action to recover an overpayment.

Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts, collective bargaining agreements, and a copy of the latest annual report (Form 5500 series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

Obtain, upon written request to the Plan Administrator, copies of all documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 series) and updated Summary Plan Description. The Plan Administrator may apply a reasonable charge for the copies.

Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

Continue Plan coverage for your eligible spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. However, your spouse or your dependents may have to pay for such coverage. Review this SPD and the documents governing the Plan for the rules governing COBRA continuation coverage rights.

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of the Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit from the Plan, or from exercising your rights under ERISA.

If your claim for a welfare benefit under an ERISA-covered plan is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Administrator. If you have a claim for benefits that is denied or ignored in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in federal court. If it should happen that plan fiduciaries misuse the Plan’s money or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees (e.g., if it finds your claim is frivolous).

If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance obtaining documents from the Plan Administrator, you should contact the nearest office of the U.S. Department of Labor, Employee Benefits Security Administration listed in your telephone directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Ave., N.W., Washington, D.C., 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

The Plan is dedicated to maintaining the privacy of your health information.  The Plan is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information or “Protected Health Information” (“PHI”) and to inform you about:

• the Plan’s uses and disclosures of 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” or “PHI” includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, electronic). The Plan is required by law to maintain the privacy of PHI and to provide individuals with notice of its legal duties and privacy practices.

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 all PHI received or maintained by the Plan, including PHI received or maintained prior to the change. If a privacy practice described in this Notice is materially changed, a revised version of this notice will be provided to all individuals then covered under the Plan for whom the Plan still maintains PHI. The revised notice will be provided by mail or by another method permitted by law.

Any 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.

Please note that the Plan Sponsor obtains summary PHI, enrollment and disenrollment, termination of coverage and specific appeals information from the Plan. Most records containing your PHI are created and retained by the Third Party Administrator for the Plan. In the event that the Plan Sponsor receives PHI, the Plan has been amended to require that the Plan Sponsor only use and disclose PHI received from the Plan for plan administrative purposes or as otherwise permitted by federal law. This notice only applies to Protected Health Information or PHI as defined in the applicable HIPAA privacy rules.

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.

A. 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. The Plan also will disclose PHI to the Plan Sponsor for plan administrative purposes or as otherwise permitted by law. The Plan Sponsor has amended its plan documents to protect your PHI as required by federal law.

The Plan contracts with business associates for certain services related to the Plan. PHI about you may be disclosed to the business associates so that they can perform contracted services. To protect your PHI, the business associate is required to appropriately safeguard the protected health information. The following categories describe the different ways in which the Plan and its business associates may use and disclose your PHI.

B. 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.

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 cardiologist the name of your treating physician so that the cardiologist may ask for your lab results from the treating physician.

Payment includes but is not limited to actions 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.

C. Authorized uses and disclosures

You must provide the Plan with your written authorization for the types of uses and disclosures that are not identified by this notice or permitted or required by applicable law.

Any authorization you provide to the Plan regarding the use and disclosure of your health information may be revoked at any time in writing. After you revoke your authorization, the Plan will no longer use or disclose your health information for the reasons described in the authorization, except for the two situations noted below:

• The Plan has taken action in reliance on your authorization before it received your written revocation; or
• You were required to give the Plan your authorization as a condition of obtaining coverage.

D. 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:

• When required by law.
• When permitted for purposes 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.
• 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.
• 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).
• 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.
• For law enforcement purposes, including to report certain types of wounds or for the purpose of identifying or locating a suspect, fugitive, material witness or missing person. The Plan may also disclose PHI 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.
• 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 decedent.
• For research, subject to conditions.
• 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.
• When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.

Notwithstanding the above, and to the extent provided in applicable law, the Plan shall not use or disclose your PHI that is classified as genetic information for purposes of any underwriting activity.

A. Right to Request Restrictions on PHI Uses and Disclosures

You may request that the Plan restrict uses and disclosures of your PHI to carry out treatment, payment or health care operations, or 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.

With respect to a health care provider, you have a right to request that a health care provider restrict disclosure of your PHI and not disclose such PHI and related claim information to the Plan, if the PHI pertains solely to a health care item or service for which you or another person on your behalf has paid the health care provider and you have not requested reimbursement from the Plan.

The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations as required by law. 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 the Plan at the address provided at the end of this Notice specifying the requested method of contact or the location where you wish to be contacted.

B. Right to Inspect and Copy PHI

With certain exceptions described below, you have the right to inspect and copy your PHI if it is part of a “Designated Record Set” or “DRS.” The DRS is the group of records maintained by or on behalf of the Plan contained in the enrollment, payment, claims adjudication, and case or medical management record systems of the Plan, and any other records which are used by the Plan to make decisions about individuals. This right does not extend to psychotherapy notes, information gathered for certain civil, criminal or administrative proceedings, and information maintained by the Sponsor that duplicates information maintained by a Plan business associate in its DRS.

The Plan must provide you with access to the PHI contained in a DRS in the form and format requested by you. However, if the PHI is not readily producible in such form or format, it must be produced in a readable hard copy form or such other form as agreed to by the Plan and you. Further, if the PHI is maintained in an electronic DRS, you may request an electronic copy of the PHI in an electronic form or format. However, if the PHI is not readily producible in a specific electronic form and format requested by you, the Plan and you must agree on the electronic form or format in which it will be produced.

If you request a copy of your PHI contained in a DRS, the Plan may charge you a reasonable, cost-based fee for the expense of copying, mailing and/or other supplies associated with your request. To inspect and obtain a copy of your PHI that is part of a DRS, you must submit your request in writing.

If you exercise your right to access your PHI, the Plan will respond to your request within 30 days, subject to a one-time extension of an additional 30 days. In the case of an extension, the Plan must provide you with a written explanation for the delay and the date by which it will respond to your request.

The Plan may deny your request to inspect and copy your PHI in certain limited situations. If you are denied access to your PHI, you will be notified in writing. The notice of denial will include the basis for the denial, and a description of any appeal rights you may have and the right to file a complaint with the Plan or with the Department of Health and Human Services. If the Plan does not maintain the PHI that you are seeking but knows where it is maintained, the Plan will notify you of where to direct your request.

C. Right to Amend PHI

If you believe that your PHI in a DRS is incorrect or incomplete, you may request that the Plan amend the PHI. Any such request must be made in writing and must include a reason that supports your requested amendment. The Plan must respond to your request within 60 days. If the Plan is not able to respond within this 60-day period, it may have a one-time 30-day extension by providing you with a written explanation for the delay and the date by which it will respond to your request.

In limited situations, the Plan may deny your request to amend your PHI. For example, the Plan may deny your request if (1) the PHI was not created by the Plan (except where you are unable to request an amendment from the person or entity that created the PHI because the person or entity is no longer available); (2) the Plan determines the information to be accurate or complete; (3) the information is not part of the DRS; or (4) the information is not part of the information which you would be permitted to inspect and copy, such as psychotherapy notes. If your request is denied, you will be notified in writing. The notice of denial will include the basis for the denial, a description of your right to submit a statement of disagreement and a description of your right to file a complaint with the Plan or with the Department of Health and Human Services.

D. Right to Receive an Accounting of PHI Disclosures

You have the right to request an accounting of certain types of disclosures of your PHI made by the Plan during a specified period of time. You do not have the right to request an accounting of all disclosures of your PHI. For example, you do not have the right to receive an accounting of (1) disclosures for purposes of Treatment, Payment or Health Care Operations; (2) disclosures to you or your personal representative regarding your own PHI; (3) disclosures pursuant to an authorization; or (4) disclosures prior to April 14, 2003 (or the inception of the Plan, whichever is later).

Your request must indicate the time period for which you are seeking the accounting, such as a single month, six months or two calendar years. This time period may not be longer than six [6] years and may not include any disclosures of PHI made before April 14, 2003 (or the inception of the Plan, whichever is later). The Plan must respond to your request within 60 days. If the Plan is not able to respond within this 60-day period, it may have a one-time 30-day extension by providing you with a written explanation for the delay and the date by which it will respond to your request.

The Plan will provide the first accounting you request in any 12-month period free of charge. The Plan may impose a reasonable, cost-based fee for each subsequent accounting request within the 12-month period. The Plan will notify you in advance of the fee and provide you with an opportunity to withdraw or modify your request.

E. The Right to Receive a Paper Copy of This Notice Upon Request

To obtain a paper copy of this Notice at any time contact the Plan Administrator. The Notice is also posted on the Plan Sponsor’s intranet site. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice.

F. 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.

Under HIPAA, the Plan and its business associates, are required to maintain the privacy and security of your PHI. The goal of the Plan and its business associates is to not allow any unauthorized uses or disclosures of your PHI. However, regrettably, sometimes an unauthorized use or disclosure of your PHI occurs. These incidents are referred to as “breaches.” If a breach affects you and is related to unencrypted PHI, the Plan or its applicable business associate will notify you of the breach and the actions taken by the Plan or the business associate to mitigate or eliminate the exposure to you.

If you believe that your privacy rights have been violated, you may complain to the Plan in care of the Plan Administrator. 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.

If you have any questions regarding this Notice or the subjects addressed in it, you may contact the Plan Administrator.

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 45 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.

If you wish to exercise one or more of the rights listed in this Notice, contact the Plan Administrator.

• Employees who retired before December, 2004, AND who were Medicare-eligible on or before December 31, 2004, and
• Eligible spouses/partners/children of retirees described above who themselves were Medicare-eligible on or before December 31, 2004, and
• Employees who reached age 65 by June 30, 2005, provided written notice by December 31, 2004 of their intent to retire by June 30, 2005, and did retire by that date.

Note that Group 1 does not include the following: Employees who retired at age 50-59 between April 15, 1986 and June 30, 1996. Note that Group 1a is a subset of Group 1 who were participating in the BlueCross BlueShield Comprehensive Plan as of December 31, 2018.

• Employees who were hired before January 1, 2004 who were age 35 or older on January 1, 2008 who retired after December 31, 2004,
• Employees who retired before December 31, 2004 but were not Medicare-eligible as of December 31, 2004, and
• Eligible spouses/partners/children of retirees in either Group 1 or Group 2 who themselves were not Medicare-eligible as of December 31, 2004.

• Employees who were hired on or after January 1, 2004, and
• Employees hired before January 1, 2004 who were under age 35 on January 1, 2008.