Required Annual Notices

Multnomah County Health Plan Required Annual Notices

2023 Annual Required Notices

(Plan Year: January 1 - December 31)

Multnomah County 2023 Required Notices (125.58 KB) (125.58 KB) (pdf)

This document includes:

• Medicare Part D Notice
• Newborns’ and Mothers’ Health Protection Act Notice
• Women’s Health and Cancer Rights Act Enrollment Notice
• Special Enrollment Rights Notice
• HIPAA Privacy Notice
• CHIP- Children’s Health Insurance Program Notice
• Non-Grandfathered Patient Protection Notice (Kaiser)
• No Surprise Billing

If you'd like a copy any of these notices, you can print out or contact the Benefits office at employee.benefits@multco.us.

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2022 Annual Required Notices

(Plan Year: January 1 - December 31)

Women's Health and Cancer Rights Act

Reconstructive Surgery Following Mastectomy

A 1998 law requires that group health plans sponsored by public and private employers provide coverage for certain reconstructive surgery following a mastectomy. 

Benefit Requirement
A group health plan that provides medical and surgical benefits with respect to a mastectomy must also cover:

• all stages of reconstruction of the breast on which the mastectomy has been performed;
• surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• prostheses and treatment of physical complications of all stages of mastectomy, including lymph edemas.

The benefits must be provided to each participant and beneficiary who receives benefits for a mastectomy, and who elects breast reconstruction in connection with the mastectomy in a manner determined in consultation with the attending physician and the patient. The same deductibles, copayments, and coinsurance provisions that apply to other medical, hospital, and surgical benefits will also apply to mastectomy-related services and procedures.

Plans are generally prohibited from denying eligibility for coverage or otherwise penalizing individuals by reducing or limiting benefits.

How this Requirement Affects our Medical Plans
Multnomah County’s medical plans were amended effective July 1, 1999, to include the benefit requirements listed above and the change is reflected in our current Member Handbooks. However, federal law requires that the benefit detail be disclosed on an annual basis. Therefore, we are distributing this notice to be in compliance with federal law.

Dated: October 4, 2021

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Newborns' and Mothers’ Health Protection Act Notice

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section.  However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).  In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the Plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

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HIPAA - NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Multnomah County offers health plan benefit options to its employees, retirees and eligible family members. Some plans are self funded for which the County funds and pays claims. This notice describes the privacy practices that the County has established for self funded plans which are managed by third party administrators. We are required by law to maintain the privacy of your protected health information (“Information”) and to give you this notice of our legal duties and privacy practices. We are required to follow the terms of the notice currently in effect. This notice is effective on July 1, 2013. We reserve the right to change this notice. Any changes will apply to Information that we already have about you. We will post a current copy of this notice online at: multco.us/benefits/hipaa.

YOUR RIGHTS

We are prohibited from using or disclosing genetic information for underwriting purposes. 

Inspect and Copy:You have the right to inspect or copy your Information held in a “designated record set”. A “designated record set” is a group of records that is used to make decisions about you. We may limit the Information that you can inspect or copy in limited circumstances. If we limit your right to inspect or copy, you can ask in writing for a review of that decision.Copies of records may be provided to you or a third party that you identify in an electronic or paper format depending on your request and the technology in which the records are maintained. Your request must be in writing. We can help you make a written request. We may charge you a fee for copies.

Amendment:You have the right to ask us to change some of the Information in your designated record set that you believe is incorrect or incomplete. Your request must be in writing and provide a reason. We can help you make a written request. We will tell you in writing if we deny your request and you have the right to respond to our denial. You also have the right to have your request, the denial and a statement of disagreement, if any, included in future releases of your record.

Accounting:You have the right to ask for a list of certain disclosures of your Information in your designated record set. The list will not include disclosures made for treatment, payment, or health care operations, disclosures made to you or individuals involved in your care or payment for care. It also will not include disclosures made prior to 6 years before the date of the request, pursuant to an authorization, to a correctional facility, incidental disclosures, disclosures made for national security or intelligence, or disclosures made prior to April 14, 2003.   Your request must be in writing. We can help you make a written request. We may charge you a fee if you ask for a list more than once every 12 months.

Restrictions:You have the right to ask us to limit how your Information is used or disclosed. We are not required to accept your request and we may be unable to do so. Your request must be in writing. We can help you make a written request. 

Confidential Communications:You have the right to ask us to communicate with you at a certain place in a certain way. You must specify how or where you wish to be contacted. For example, you can ask that we only contact you at work. We will accommodate any reasonable request.

Notice:You have the right to receive a paper copy of this notice upon request.  This notice can be made available in other languages and alternative formats.

Breach Notice:You have the right to be notified in the event that we discover a breach of unsecured Information.

Complaints:You have the right to file a complaint if you believe we have violated your privacy rights. You may file a complaint with our Privacy Officer or with the Secretary of the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint.

HOW WE MAY USE AND DISCLOSE YOUR INFORMATION WITHOUT YOUR AUTHORIZATION

Treatment: We may use or disclose your Information as necessary to health care provider(s) to assist with your treatment. For example, we may disclose your Information to providers or hospitals that provide treatment to you. 

Payment: We may use or disclose your Information to pay for the services you receive. For example, to determine the plan’s responsibility for providing benefits under the plan or for coordination of benefits.

Health Care Operations: We may use or disclose your Information for business operations. For example, to review plan performance, fraud or abuse detection, or for underwriting purposes.

Individuals Involved in Your Care or Payment for Your Care: We may disclose Information to your family, personal representative or others involved in your care or payment for care if you give verbal permission or otherwise do not object.

Public Health Activities: We may use or disclose Information about you for public health activities. For example, disclosures made for the purpose of preventing or controlling disease, injury, disability, abuse or neglect.  These activities include activities performed by organ or tissue donation and transplantation services, activities performed by coroners, medical directors, and funeral directors, and activities necessary to avoid a serious threat to the imminent health and safety of you or others.

Health Oversight Activities: We may disclose Information to a health oversight agency. Activities include audits and inspections for the government to monitor the health care system.

Legal Proceedings: We may disclose Information about you in response to a court order, subpoena, discovery request, activities related to workers’ compensation benefits, or other lawful purpose.

Law Enforcement: We may disclose Information about you to the police or other people who enforce the law when this disclosure is permitted or required by law.  We may disclose Information to report a crime on our premises.

Research: Under certain circumstances, we may use and disclose your Information for research approved by an Institutional Review or Privacy Board or through an authorization signed by you.

Inmates: If you are an inmate of a jail or prison or under the custody of law enforcement, we may disclose Information as required or permitted by law.

Business Associates: In certain situations, we may need to disclose your Information with a business associate, such as a translator or quality assurance reviewer, so it can perform a service on our behalf. We will have a written agreement with the business associate requiring it to protect the privacy of your Information under the same privacy protections that we provide. 

Military and National Security: We may disclose your Information as required by armed forces personnel or to federal officials authorized for national security and intelligence activities. 

Disaster Relief Efforts: Unless you object, we may disclose your Information to other health care providers or to an entity assisting in a disaster relief effort to coordinate care. We may disclose your Information as necessary to identify, locate and notify family members, guardians or others responsible for your care, location, condition or death. 

Limited Data Set: We may disclose limited Information to third parties for purposes of research, public health or health care operations. This disclosure will not include any Information which can be used to directly identify you. 

Incidental Disclosures: Incidental disclosures of your Information may occur as a byproduct of permissible uses and disclosures. 

Required or Permitted by Law: We may use or disclose your Information when permitted or required by federal, state or local law. 

Marketing: We may communicate with you face-to-face about products or services that may interest you or give you a promotional gift of nominal value.  Otherwise, we do not use or disclose your Information for marketing without your authorization.  

Plan Sponsor: For the purpose of plan administration, the plan may disclose your Information with the plan sponsor.  

DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

Other Laws Protecting Health Information: Other laws may require your written authorization to disclose your Information about certain mental health, alcohol and drug abuse treatment, HIV/AIDS testing or treatment, and genetic testing. We must obtain authorization for the use and disclosure of psychotherapy notes and the sale of your Information. 

Uses and disclosures other than those permitted will only be made with your written authorization. If you authorize us to use or disclose your Information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your Information for the purposes given in the written revocation. The revocation will not affect disclosures previously made in reliance on your authorization. 

FOR MORE INFORMATION

If you have any questions about this notice or need more information, please contact Multnomah County Privacy Officer, Employee Benefits Office, 501 SE Hawthorne Blvd Suite 400, Portland, OR 97214 or call 503-988-3477.

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MEDICARE PRESCRIPTION COVERAGE – PART D

If you or your dependents aren't currently covered by Medicare and won't become eligible in the next 12 months, this notice doesn't apply to you.

Medicare introduced prescription drug coverage on January 1, 2006 requiring employers to notify their Medicare-eligible health plan members annually if their employer’s group health plan coverage is equal to Medicare’s Part D prescription drug coverage. 

The County health plans offer prescription drug coverage that is at least as good as the standard Medicare Part D prescription coverage. This means if you are Medicare eligible, you can decline to enroll in a Medicare Part D program and not suffer a penalty premium if you decide at a later time to enroll in a Medicare Part D plan.

Note: Employer-sponsored prescription drug coverage for domestic partners is not considered creditable coverage under Medicare. Therefore, if your domestic partner does not enroll for Medicare prescription drug coverage at the time they are initially Medicare eligible, Medicare may apply late enrollment penalties when your domestic partner later enrolls in Medicare.

Below you will find the required notification for Cigna plan members and Kaiser plan members. If you or your spouse are Medicare eligible, retain the applicable notice for your records.

Notification Date: October 4, 2021

Important Notice from Multnomah County About Your Prescription Drug Coverage and Medicare
Kaiser Plan Participants

This notice has information about your current prescription drug coverage with Multnomah County and prescription drug coverage available for people with Medicare. It also tells you where to find more information to help you make decisions about your prescription drug coverage.

1. Medicare prescription drug coverage is available to everyone with Medicare. This prescription coverage is referred to as Medicare Part D.
2. Multnomah County has determined the prescription drug coverage offered by the Kaiser 10/20 Medical Plan, the Kaiser Standard Medical Plan, the Kaiser Senior Advantage Medical Plan, and Kaiser Maintenance Medical Plan is expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered "Creditable Coverage".
3. Read this notice carefully - it explains the options you have under the Medicare prescription drug coverage, and can help you decide whether or not you want to enroll in the Medicare prescription drug plan.

Prescription drug coverage is available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans might also offer more coverage for a higher monthly premium.

People with Medicare Part A (hospitalization) and/or Part B (medical) can enroll in a Medicare Part D (prescription drug plan). However, because you have existing prescription drug coverage that, on average, is as good as Medicare coverage, you can choose to not to enroll in a Medicare prescription plan if you are currently eligible.

Because your existing coverage through Multnomah County is at least as good as the standard Medicare prescription drug coverage, you can keep your Multnomah County coverage, decline to enroll in the Medicare prescription coverage and not pay a late penalty when you enroll in Medicare prescription coverage.

You will have the opportunity to enroll in a Medicare Prescription Drug Plan annually during the Medicare enrollment period (between October 15 and December 7). If you decline the Medicare prescription drug coverage and elect to enroll in the Medicare prescription drug coverage during a future Medicare enrollment period, you will not have to pay a higher premium for the Medicare prescription drug coverage, assuming you continue your County sponsored coverage listed above. However, if you lose creditable prescription drug coverage, through no fault of your own, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare Part D plan. In addition, if you lose or decide to leave employer coverage; you will be eligible to join a Medicare Part D plan at that time using an Employer Group Special Enrollment Period.

Please note: At the County, your prescription coverage is included with your medical and vision coverage. Kaiser does not offer retirees the option of dropping only prescription coverage. If you are currently enrolled in the Senior Advantage Plan and you elect to enroll in a separate Medicare Part D Prescription Drug program, YOU WILL BE DROPPED FROM THE KAISER SENIOR ADVANTAGE PLAN. Retirees and/or the family members of retirees who elect to discontinue their Multnomah County health plan coverage, will be terminating all medical, vision and prescription coverage and WILL NOT be allowed to re-enroll in the County retiree health plans at some later time.

Senior Advantage Health Plan Members: If you or a family member are enrolled in Kaiser’s Senior Advantage Plan, this plan includes Medicare Prescription Drug coverage as a component of the plan’s benefits. Therefore, your coverage under the Senior Advantage Plan is, by definition, equal to or better than the standard Medicare Prescription Drug coverage. Your Senior Advantage coverage is creditable and you do not have to enroll in a separate Medicare Part D Prescription Drug Plan.

Active employees and/or their dependents who are Medicare eligible may choose to carry their coverage through the Kaiser Senior Advantage Plan:

• If you are an active employee or covered dependent of an active employee, enrolled in Senior Advantage Plan: Should you enroll in a Medicare Part D, you will be removed from the Senior Advantage Plan but you will remain covered under the Kaiser active employee plan. The Medicare Part D prescription coverage you purchase will be unrelated to your Kaiser coverage. You will need to choose which program you will use to purchase your medication. The two programs will not coordinate benefits.
• If you are an active employee or covered dependent of an active employee, not enrolled in Senior Advantage Plan: The Medicare Part D prescription coverage you purchase will be unrelated to your Kaiser coverage. You will need to choose which program you will use to purchase your medication. The two programs will not coordinate benefits.

You should also know that if you drop or lose your coverage with Multnomah County and don’t enroll in Medicare prescription drug coverage after your current County coverage ends, you may pay more to enroll in Medicare prescription drug coverage later. If you go 63 days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly premium will go up at least 1% per month for every month after your initial enrollment period that you did not have that coverage. For example, if you go nineteen months without coverage, your premium will always be at least 19% higher than what most other people pay. You’ll have to pay this higher premium as long as you have Medicare coverage. In addition, you may have to wait until the next annual Medicare Part D enrollment (held in October) to enroll.

For more information about this notice or your current prescription drug coverage:
Contact the Multnomah County Employee Benefits Office. Our office is located at 501 SE Hawthorne 3rd Floor. Our telephone number is (503) 988-3477. Our email address is Employee.Benefits@multco.us.

NOTE: You may receive this notice at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage changes. You also may request a copy from our office at any time.

For more information about your options under Medicare prescription drug coverage…
More detailed information about Medicare plans that offer prescription drug coverage is available in the “Medicare & You” handbook. If you are Medicare-eligible, you’ll get a copy of the handbook in the mail from Medicare. You may also be contacted directly by Medicare prescription drug plans. You can also get more information about Medicare prescription drug plans from these places:

• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help.
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: October 4, 2021

Important Notice from Multnomah County About Your Prescription Drug Coverage and Medicare
Cigna Plan Participants

This notice has information about your current prescription drug coverage with Multnomah County and prescription drug coverage for people with Medicare. Includes information to help make decisions about your prescription drug coverage.

If you and/or your family members are not Medicare eligible, this does not apply to you. Federal regulations dictate employers must attempt to inform any plan member who may be affected by the availability of Medicare prescription drug coverage.

Multnomah County is sending this notice out to our active employees because, even though you are actively working, you may also be Medicare eligible or you may have a family member enrolled under your County health plan coverage who is Medicare eligible.

1. Medicare prescription drug coverage is available to everyone with Medicare. This prescription coverage is referred to as Medicare Part D.
2. Multnomah County has determined the prescription drug coverage offered by the Cigna PPO 400 Plan, the Cigna Performance Plan, the Cigna Preferred Plan, and the Cigna Major Medical Plan is expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage.
3. Read this notice carefully - it explains the options you have under the Medicare prescription drug cover-age, and can help you decide whether or not you want to enroll in the Medicare prescription drug plan.

Prescription drug coverage is available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans might also offer more coverage for a higher monthly premium.

Because your existing coverage through Multnomah County is on average at least as good as the standard Medicare prescription drug coverage, you can keep your Multnomah County coverage, decline to enroll in the Medicare prescription coverage, and not pay a late penalty when you enroll in Medicare prescription coverage.

People with Medicare Part A (hospitalization) and/or Part B (medical) can enroll in Medicare Part D (prescription drug plan). However, because you have existing prescription drug coverage that is as good - on average - as Medicare coverage, you can choose not to enroll in the Medicare prescription drug plan, if you are eligible.

You will have the opportunity to enroll in a Medicare Prescription Drug Plan annually during the Medicare enrollment period (between October 15 and December 7). If you decline the Medicare prescription drug coverage and elect to enroll in the Medicare prescription drug coverage during a future Medicare enrollment period, you will not have to pay a higher premium for the Medicare prescription drug coverage, assuming you continue your County sponsored coverage listed above.

Current employees: If you decide to enroll in and purchase a Medicare prescription drug plan, since you are covered as an active employee, your Medicare Part D coverage will be secondary to your existing WellDyneRx coverage. You need to purchase your medications using your WellDyneRx program and then file claims with your Medicare prescription plan to obtain secondary benefits (if any) via the Medicare plan.

Retirees: If you decide to enroll in and purchase a Medicare prescription drug plan and your County Health plan coverage as a Retiree, your Medicare Part D coverage will be primary to your existing WellDyneRx coverage. You need to purchase your medications using your Medicare Part D coverage then file claims with WellDyneRx as your secondary prescription coverage plan.

Multnomah County does not offer health plan members the option of dropping their County sponsored prescription coverage.

If you drop or lose your coverage with Multnomah County and don’t enroll in Medicare prescription drug coverage after your County coverage ends, you may pay more to enroll in Medicare prescription drug coverage later. If you go 63 days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly premium will go up 1% per month for every month you did not have that coverage after your initial enrollment period. For example, if you go 19 months without coverage, your premium will always be at least 19% higher than what most other people pay. You’ll have to pay this higher premium as long as you have Medicare coverage. In addition, you may have to wait until the next annual Medicare Part D enrollment (held each November) to enroll. However, if you lose creditable prescription drug coverage, through no fault of your own, you will be eligible for a two (2) month Special Enrollment Period (SEP), because you lost creditable coverage, to join a Medicare Part D plan. In addition, if you lose employer sponsored coverage, you will be eligible to join a Part D plan at that time using an Employer group Special Enrollment Period.

For more information about this notice or your current prescription drug coverage…
Contact the Multnomah County Employee Benefits Office. Our office is located at 501 SE Hawthorne 3rd Floor. Our telephone number is (503) 988-3477. Our email address is employee.benefits@multco.us. NOTE: You may request a copy of this notice from our office at any time.

For more information about your options under Medicare prescription drug coverage…
More detailed information about Medicare plans that offer prescription drug coverage is available in the “Medicare & You” handbook. If you are Medicare-eligible, you’ll get a copy of the handbook in the mail from Medicare. You may also be contacted directly by Medicare prescription drug plans. You can also get more information about Medicare prescription drug plans from these places:

• Visit www.medicare.gov.
• Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help.
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Name of Sender: Multnomah County
Contact: Employee Benefits Office
Mailing Address: 501 SE Hawthorne Blvd., Suite 400, Portland, OR 97214
Phone Number: (503) 988-3477

Remember: Keep this notice. If you enroll in one of the plans approved by Medicare which offer prescription drug coverage, you may need to give a copy of this notice when you join to show that you are not required to pay a higher premium amount.

Date: October 4, 2021

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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2020. Contact your State for more information on eligibility.

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Patient Protection Disclosure—Required Notice for Kaiser Permanente Health Plans

Kaiser Permanente generally requires the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider.

For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Kaiser Permanente at KP.org or Membership Services at 503-813-2000 or 800-813-2000.

You do not need prior authorization from Kaiser Permanente or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals.

For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Kaiser Permanente at KP.org or Membership Services at 503-813-2000 or 800-813-2000.

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Kaiser Permanente Health Plans ACA 1557 Non-Discrimination Notice

Kaiser Foundation Health Plan of the Northwest (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

We also:

 Provide no cost aids and services to people with disabilities to communicate effectively with us, such as:
 Qualified sign language interpreters
 Written information in other formats, such as large print, audio, and accessible electronic formats
 Provide no cost language services to people whose primary language is not English, such as:
 Qualified interpreters
 Information written in other languages

If you need these services, call:
Oregon 1-800-813-2000
Washington 1-800-813-2000
TTY 711

If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Kaiser Civil Rights Coordinator, 500 NE Multnomah St., Ste 100, Portland OR 97232, telephone number: 1-800- 813-2000. You can file a grievance by mail or phone. If you need help filing a grievance, the Kaiser Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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Moda ACA 1557 Non-Discrimination Notice

Delta Dental ACA 1557 Non-Discrimination Notice

Delta Dental follows federal civil rights laws. We do not discriminate on the basis of race, color, national origin, religion, age, disability, gender identity, sex or sexual orientation.
Delta Dental provides free services to people with disabilities so that they can communicate with us. These include sign language interpreters and other forms of communications. If your primary language is not English, Delta Dental will give you interpretation services and/or materials written in other languages.

If you need any of the services listed above, contact:
Customer Service,
888-217-2365 (TDD/TTY 711)
If you think Delta Dental did not offer these services or discriminated in another way on the basis of race, color, national origin, religion, age, disability, gender identity, sex or sexual orientation, you can file a written grievance by mailing or faxing it to:

Delta Dental of Oregon
Attention: Appeal Unit
601 SW Second Ave.
Portland, OR 97204
Fax: 503-412-4003
Delta Dental’s efforts to assure nondiscrimination are coordinated by:
Dave Nessler-Cass, Chief Compliance Officer
601 SW Second Ave. Portland, OR 97204 855-232-9111
compliance@modahealth.com 

If you need assistance filing a grievance, please call Customer Service.

You can file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights at ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone to:
U.S. Department of Health and Human Services
200 Independence Ave. SW, Room 509F
HHH Building, Washington, DC 20201
800-368-1019, 800-537-7697 (TDD).

Office for Civil Rights complaint forms are available at
hhs.gov/ocr/office/file/index.html
Dental plans in Oregon provided by Oregon Dental Service, dba Delta Dental Plan of Oregon. 0569 (8/20)
 

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Cigna Non-Discrimination Notice

Cigna complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Cigna:
• Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats,
other formats)
• Provides free language services to people whose primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact customer service at the toll-free number shown on your ID card, and ask a Customer Service Associate for assistance. If you believe that Cigna has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by sending an email to ACAGrievance@Cigna.com or by writing to the following address:
Cigna
Nondiscrimination Complaint Coordinator
PO Box 188016
Chattanooga, TN 37422

If you need assistance filing a written grievance, please call the number on the back of your ID card or send an email to ACAGrievance@Cigna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, DC 20201
1.800.368.1019, 800.537.7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.

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Your Rights and Protections Against Surprise Medical Bills

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

• Your health plan generally must:

• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you have received a surprise bill you believe is not allowed under the new Federal law (No Surprises Act) , you can file an appeal with your insurance company, then ask for an external review of the company’s decision after the initial appeal is completed with your plan.

If you believe you’ve been wrongly billed, you may contact the U.S. Department of Health and Human Services to file a complaint by calling 800-985-3059 (toll-free) or visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

You can also contact Oregon’s Division of Financial Regulation to speak with a consumer advocate or file a complaint in any of the following ways:
• Phone: 888-877-4894 (toll-free)
• Email: DFR.InsuranceHelp@dcbs.oregon.gov

https://dfr.oregon.gov/help/complaints-licenses/Pages/file-complaint.aspx