Regulatory Notices

Claims should always be submitted to the primary plan first.

For Urgent Care Claims

If you file an urgent care claim, the Claims Administrator will make an initial benefit determination within 24 hours after they receive your properly completed claim form and all required documentation.

An urgent care claim is a claim filed before medical services are received and is for conditions in which receiving medical care quickly is a critical factor in:

• assuring the patient’s life, health or ability to regain maximum function
• or, in the opinion of a physician with knowledge of the patient’s medical condition, avoiding severe pain.

If you file an incomplete urgent care claim, the following steps show the procedure and timing:

• Within 24 hours after receiving your claim, the Claims Administrator will notify you that your claim is incomplete and tell you what information you need to provide.
• You provide the requested information within the timeframe set by the Claims Administrator (but in no case less than 48 hours).
• The Claims Administrator makes a final determination on the claim within 48 hours after:
  • you provide the requested information, or
  • the end of the time period you have to provide the requested information

  … whichever is earlier.

For Post Service Claims

If you file a post service claim, the Claims Administrator will send you written notification of their benefit determination within 30 days after receiving the claim. If matters beyond the control of the Claims Administrator require an extension of time, the Claims Administrator may extend the notification period by up to 15 days. If an extension is required, the Claims Administrator will notify you in writing before the end of the initial 30-day period. The notification will include the reasons the extension is required and the date by which the Claims Administrator expects to make its determination.

If the extension is required because your claim was not complete, the notice of extension will describe the required information. You will have at least 45 days following receipt of the notice to provide the requested information.

A post service claim is a claim for benefits filed after the services are received.

If Your Claim Is Denied

If your claim for benefits is denied, in whole or in part, you will receive a written notice. This notice will include the following:

• The specific reasons for the denial of your claim
• The specific references in the Plan document that support those reasons
• A description of the information you must provide to perfect your claim and the reasons why that information is necessary
• A discussion of the procedure available for further review of your claim, including your right to file a civil action following an adverse benefit determination on review
• If the denial relies on an internal rule, protocol or guideline, such rule, protocol or guideline, or a statement that it will be provided free of charge to you upon request
• If the denial is based on a medical necessity or an experimental treatment, an explanation of the clinical or scientific reasoning for denial of the claim, or a statement that it will be provided to you free of charge upon request

In the case of a denial of an urgent care claim, the notice also will set forth a description of the expedited review process for an urgent care claim

Your Right to Appeal

You have the right to appeal a denial of your claim. You must submit a written appeal to the insurance company within 180 days after you receive the claim denial notice. In preparing your appeal, you shall be entitled to request and receive, free of charge, copies of any documents, records or other pertinent information associated with your claim. This pertinent information includes any information in the initial benefit determination that was considered or generated (even if not relied on) and the identity of any medical expert who was consulted (even if not relied on). Any of this information may be submitted for determination, even if it was not considered in the initial benefit determination.

The insurance company will conduct a full and fair review of your appeal and it will not give deference to the initial benefit determination. The appeal shall be heard by an appropriate individual (or individuals), who is not the person having made the initial benefit determination or a subordinate of that person. This reviewer on appeal also may consult with a medical professional, who was not consulted or a subordinate of any person consulted in the initial benefit determination.

If your appeal involves an urgent care claim, the insurance company shall notify you of the decision as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of your appeal. You may request an expedited appeal, which may be made either orally or in writing and allows all necessary communication between you and the administrator to take place via telephone, facsimile or other equally expeditious method.

If your appeal involves a pre-service claim, the insurance company will notify you of the decision within 30 days after receipt of your appeal.

If your appeal involves a post-service claim, the insurance company will notify you of the decision within 60 days after receipt of your appeal.

If your appeal is denied, in whole or in part, the insurance company will provide you with a notice with the following:

• The specific reasons for the denial including the specific Plan provisions on which the denial relies
• A statement informing you of the availability of any documents, records or other relevant information free of charge upon request
• A description of any internal rule or protocol relied upon or a statement that any such rule or protocol will be provided free of charge upon request
• An explanation of any voluntary appeals procedures that may be available and a statement of your right to bring a civil action
• If the denial of an appeal is based on a medical necessity or experimental treatment, an explanation of the scientific or clinical judgment exercised or a statement that the explanation will be provided free of charge and upon request
• The following statement: “You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what might be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency.”

Throughout the claims review procedure, you may have a personal representative act on your behalf.

Any failure on your part to comply with the request for information by the Plan Administrator or insurance company may result in delay or a denial of your claim.

The insurance company has the authority to make final decisions with respect to paying claims under the Medical Plan.

If you believe that you have been improperly denied a benefit from the Plan after making full use of the claims and appeals procedure, you may serve legal process on the Plan Administrator.

Continuation Coverage (COBRA)

If healthcare coverage stops as a result of:

• Layoff, leave of absence, disability or termination of employment for reasons other than gross misconduct
• Retirement before age 65 if you do not qualify for retiree medical benefits
• A reduction in your regularly scheduled hours
• Divorce or legal separation
• A child no longer qualifying as a family member
• Your death

…you and/or your eligible family members can elect to continue coverage under the Montefiore healthcare options you had in effect at the time of the qualifying event. You will have the opportunity to change your options and coverage during the next fall annual election period. At that time, you will receive all the materials you need to make your elections. The decisions you make during the election period will take effect the following January 1.

If you (or your family members) elect continuation coverage, you must pay 102% of the cost of coverage, as determined by the COBRA Administrator. If a disability occurs within the first 60 days of COBRA continuation coverage, the 18 month period for medical coverage may be extended up to 29 months as a result of the disability. The premium for the family may increase to 150% of the cost of coverage for the additional 11 months.

You or your family members must notify Montefiore’s HR-Benefits Office in writing if healthcare coverage will stop due to any of the following events: you and your spouse are divorced or legally separated, or a child no longer qualifies as a dependent. You must send this written notification within 60 days after the date of the event or the date coverage would stop – whichever is later.

Electing Continuation Coverage

To elect continuation coverage, you must return the COBRA Election Form to the COBRA Administrator within 60 days after:

• You receive notice of your right to continue healthcare coverage
• The date healthcare coverage stops, if later

If you or a family member initially waives COBRA continuation coverage, that individual may revoke that waiver during the 60-day COBRA election period. In that case, COBRA coverage will begin on the date you first became eligible provided you pay the required retroactive contributions on a timely basis.

You have 45 days after you elect COBRA coverage to pay the premium for the period beginning on the date COBRA coverage begins until the end of the month in which you return the COBRA election form. Claims under COBRA coverage will not be processed for this initial period until payment is received by the COBRA Administrator. After the initial payment, you must pay your monthly COBRA premium on the first day of the month. If not paid within 30 days of the date payment is due, coverage will automatically terminate without further notice. Claims under COBRA coverage will not be processed for any period until full payment is received by the COBRA Administrator.

If You Have Questions

For more information about your rights and obligations under the Plans and under federal law, you should contact the COBRA Administrator who is responsible for administering COBRA continuation coverage. The COBRA Administrator is:

HealthEquity/Wageworks
PO Box 14055
Lexington, KY 40512
888.678.4881
ATTN: COBRA Department

You may also 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 www.dol.gov/ebsa.

Keep Your Program Informed of Address Changes

To protect your family's rights, you must notify the COBRA Administrator in writing of any changes in the addresses of family members. You should also keep a copy of any notices you send to the COBRA Administrator for your records.

Continuation Coverage under the Uniformed Services Employment and Re-Employment Rights Act of 1994 (USERRA)

This federal law generally allows individuals called for military service to continue coverage for themselves and their family members for up to 24 months. If military service is for 30 or fewer days, you and your family members can continue coverage at the same cost as before your service began. If military service is longer than 30 days, you and your family members may continue medical, dental and vision coverage through COBRA for up to 24 additional months by paying 102% of the full premium for coverage.

If you don’t continue your benefits during the leave or if you fail to make any of the required payments, you lose coverage effective the end of the month for which the last payment was made. You will receive information concerning your rights under COBRA at that time. When you return from leave, the benefits you had before your leave will be reinstated as required by law unless you have made changes during the fall annual election period or as a result of a qualified status change. If you do not return to employment, Montefiore may collect any unpaid contributions, as permitted by law.

State law may provide additional rights.

Resources

USERRA Notice

Duration of Continuation Coverage

The following table shows the longest period of time coverage can be continued.

Coverage Duration	Situation	Reason
18 Months	If You Lose Healthcare Coverage Due To:	Layoff, leave of absence (including military leave), termination (other than gross misconduct), or a reduction in your regularly scheduled hours.
	If Your Covered Spouse Loses Healthcare Coverage Due To:	Your spouse is on layoff, leave of absence, terminates employment (other than gross misconduct), or a reduction in regularly scheduled hours.
	If Your Covered Dependent Child Loses Healthcare Coverage Due To:	Your parent is on layoff, leave of absence, terminates employment (other than gross misconduct), or a reduction in regularly scheduled hours.
29 Months	If You Lose Healthcare Coverage Due To:	Disability at the time of termination of coverage or within the first 60 days of continuation coverage.
	If Your Covered Spouse Loses Healthcare Coverage Due To:	Your spouse is disabled at termination of employment or within the first 60 days of continuation coverage.
	If Your Covered Dependent Child Loses Healthcare Coverage Due To:	Your parent is disabled at termination of employment or within the first 60 days of continuation coverage.
36 Months	If Your Covered Spouse Loses Healthcare Coverage Due To:	The death of your spouse, your spouse is disabled, divorce, legal separation, or annulment.
	If Your Covered Dependent Child Loses Healthcare Coverage Due To:	The death of your parent, loss of dependent status for medical/dental coverage, divorce, legal separation, or annulment.

COBRA Coverage Limitations

Note: In no case can COBRA coverage continue for more than 36 months, even if you experience multiple qualifying events.

When the continuation period ends, health care benefits stop.

Continuation of healthcare coverage may be cut short if:

• You or your family members do not make all the required contributions on a timely basis
• Montefiore terminates all health plans

Continuation of your Medical coverage will also stop if you or your family members become entitled to Medicare (coverage could continue for those individuals not eligible for Medicare for up to 36 months from the original qualifying event, provided those family members otherwise remain eligible).

 

Important Notice from Montefiore Medical Center about Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Montefiore Medical Center and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

• Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
• Montefiore Medical Center has determined that the prescription drug coverage offered by Montefiore’s medical options is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join a Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 through December 7.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens to Your Current Coverage If You Decide to Join a Medicare Drug Plan?

If you decide to join a Medicare drug plan, you will still be eligible to receive all of your current health and prescription drug benefits, provided you continue your Montefiore coverage.

If you do decide to join a Medicare drug plan and drop your current Montefiore coverage, be aware that you and your dependents will not be able to get this coverage back.

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Montefiore Medical Center and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information about this Notice or Montefiore Prescription Drug Coverage

Call Montefiore’s HR-Benefits Office at 914.349.8531.

NOTE: You will receive this notice each year before the next period you can join a Medicare drug plan, and if Montefiore’s coverage changes. You also may request a copy.

For More Information about Your Options under Medicare Prescription Drug Coverage

• Visit www.medicare.gov for personalized help.
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” Handbook for their telephone number).
• Call 800.MEDICARE (800.633.4227). TTY users should call 877.486.2048.
• If you have limited income and resources, extra help paying for a Medicare prescription drug plan is available. Visit the Social Security Administration at www.socialsecurity.gov or call 800.772.1213 (TTY 800.325.0778).

Remember: Keep this Creditable Coverage Notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained Creditable Coverage and whether or not you are required to pay a higher premium (a penalty).

Notice Details

Date: 1/1/2025

Name of Entity/Sender: Montefiore Medical Center

Contact – Position/Office: HR Benefits Office

Address: 111 East 210th Street Bronx, NY 10467-2490

Phone Number: 914.349.8531

Paid Family Leave and the Family Medical Leave Act →

Claiming PFL Benefits →

PFL Frequently Asked Questions →

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Paid Family Leave may be taken to:

• Bond with a new child including adopted and foster children within the first 12 months following birth or placement
• Care for a seriously ill family member including your child, stepchild, parent (including stepparent), parent-in-law, spouse, domestic partner, sibling (including adopted, half, or step sibling), grandchild or grandparent
• Support families dealing with military deployments

Eligibility

If you work 20 or more hours per week, you are eligible for NYPFL benefits after 26 or more consecutive weeks (6 months) of employment. If you work less than 20 hours per week you become eligible after working 175 days.

Cost

1199SEIU Members

PFL leave will be financed and administered by the 1199 National Benefit Fund and will not be financed through associate payroll deductions.

Associates (other than 1199 and non-union)

Your PFL benefit will be paid through Montefiore’s Temporary Disability Insurance policy carrier and funded through payroll deductions.

Paid Family Leave is funded through payroll deductions. Your weekly contribution rate for 2024 is 0.373% of your weekly wage, capped at an annual maximum of $333.25.

Benefits

In 2024, you may take up to 12 weeks of paid time off with a benefit of 67% of your average weekly wage up to 67% of the New York State's Average Weekly Wage (NYSAWW), currently $1,718.15. The average weekly wage is used to determine your contributions and the maximum payable benefit. The maximum days per week of paid family leave is based on the average number of days you work per week.

Qualified Leaves

Maternity and Parental Leave

Parents expecting, fostering or adopting a child within the first 12 months following birth or placement may be eligible for Paid Family Leave, provided they have the proper documentation.

Paid Family Leave only begins after birth and is not available for prenatal conditions.

Caring for a Close Relative with a Serious Health Condition

You may qualify for paid time off if you need to care for a seriously ill family member including your child, stepchild, parent, stepparent, parent-in-law, spouse, domestic partner, sibling (including adopted, half, or step sibling), grandchild or grandparent.

A serious health condition is an illness, injury, impairment, or physical or mental condition that involves:

• Inpatient care in a hospital, hospice, or residential health care facility
• Continuing treatment or supervision by a health care provider
• Alzheimer’s disease and other related dementias or a disability resulting from the natural aging process

Conditions that do not qualify and do not meet the definition unless complications arise include: the common cold, the flu, ear aches, upset stomach, minor ulcers, headaches other than migraine, periodontal disease, routine dental or orthodontia problems.

Active Duty Military Deployment

Paid Family Leave is also available under the military provisions in the federal Family Medical Leave Act when a spouse, child, domestic partner or parent of the employee is on active duty or has been notified of an impending call or order of active duty.

Newborns' and Mothers' Health Protection

Under federal law, group health plans offering group health coverage generally may not:

• 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 delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.
• Set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.
• Require that you, your physician, or other healthcare provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours).

About This Notice

Your privacy is very important to us, and we are committed to protecting health information that identifies you (“health information”). This Notice will tell you about the ways we may use and disclose health information. We also describe your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to maintain the privacy of health information that identifies you; give you this Notice of our legal duties and privacy practices with respect to your health information and follow the terms of our Notice that are currently in effect.

This Notice applies to health care services that you receive or are paid by the Montefiore Medical Center Employee Health & Welfare Plan (“the Plan”). “Health information” includes any individually identifiable information that we obtain from you or others that relates to your past, present or future physical or mental health, the health care you have received, or payment for your health care.

The Plan may partner with the institutions that are part of Montefiore Health System for its population health management program, as well as third parties for administrative services. The Plan may share your health information among these third parties for purposes of treatment, payment and operations. All Montefiore Health System institutions will abide by the privacy requirements of this Notice, and all third parties with which we partner are required to have safeguards to protect your health information.

How We May Use and Disclose Health Information About You

For Treatment

We may use health information about you to provide you with medical treatment or services. We may disclose health information to doctors, nurses, technicians, medical students or other personnel who are involved in taking care of you. For example, a doctor treating you for a broken leg may need to know if you have diabetes, because diabetes may slow the healing process. We may also disclose health information to people outside of the Plan who may be involved in your medical care.

For Payment

We may use and disclose health information so that we may process your claims for treatment and health care services, and to collect your contributions for the cost of coverage under the Plan. For example, we may need to give information about your treatment to a third-party administrator in order for the Plan to pay for that treatment.

For Healthcare Operations

We may use and disclose health information for healthcare operations purposes. These uses and disclosures are necessary for the coordination of your care and for the improvement of the delivery to your care under our population-wide health improvement efforts. For example, we may use health information to review the treatment and services you receive to check on the performance of our staff in caring for you. performance of our staff in caring for you. We also may disclose information to doctors, nurses, technicians, medical students and other personnel for educational and learning purposes. We also may combine health information about many patients to decide what additional services we should offer, what services are not needed, and whether certain new treatments are effective.

Fundraising Activities

We may use certain information (name, address, telephone number or e-mail information, age, date of birth, gender, health insurance status, dates of service, department of service information, treating physician information or outcome information) to contact you for the purpose of raising money for Montefiore, and you will have the right to opt out of receiving such communications with each solicitation. The money raised will be used to expand and improve the services and programs we provide to the community. You are free to opt out of fundraising solicitations, and your decision will have no impact on your treatment or payment for services at Montefiore.

Family and Friends Involved in Your Care

If you do not object, we may release health information to a person who is involved in your medical care or helps pay for your care, such as a family member or close friend. We also may notify your family about your location, general condition or death, or disclose such information to an entity assisting in a disaster relief effort. We will allow your family and friends to act on your behalf to pick-up filled prescriptions, medical supplies, X-rays, and similar forms of health information, when we determine, in our professional judgment, that it is in your best interest to make such disclosures.

Patient Directory

If you do not object, we will include your name, hospital location, general condition (e.g. fair, stable, critical, etc.) and your religious affiliation in our Patient Directory while you are a patient in the hospital. This directory information, except for religion, may be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi.

Research

Under certain circumstances, we may use and disclose health information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. Before we use or disclose health information for research, however, the project will go through a special approval process, which balances the benefits of research with the patient’s need for privacy.

Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research projects or for similar purposes, so long as they do not remove or take a copy of any health information.

As Required by Law

We will disclose health information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety

We may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, will be to someone who may be able to help prevent the threat.

Business Associates

We may disclose health information to our business associates that perform functions on our behalf or provide us with services, if the health information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your health information and are not allowed to use or disclose any health information other than as specified in our contract.

Organ and Tissue Donation

If you are an organ or tissue donor, we may release health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation.

Military and Veterans

If you are a member of the armed forces, we may release health information as required by military command authorities. We also may release health information to the appropriate foreign military authority if you are a member of a foreign military.

Workers’ Compensation

We may release health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks

We may disclose health information for public health activities. These activities generally include disclosures to: a person subject to the jurisdiction of the FDA for purposes related to the quality, safety or effectiveness of an FDA-regulated product or activity; prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at-risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence and the patient agrees or we are required or authorized by law to make such disclosure.

Health Oversight Activities

We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.

Lawsuits and Disputes

If you are involved in a lawsuit or a dispute, we may disclose health information in response to a court or administrative order. We also may disclose health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement

We may release health information if asked by a law enforcement official for the following reasons: in response to a court order, subpoena, warrant, summons or similar process; limited information to identify or locate a suspect, fugitive, material witness or missing person; about the victim of a crime under certain limited circumstances; about a death we believe may be the result of criminal conduct; about criminal conduct on our premises; and in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

National Security and Intelligence Activities and Protective Services

We may release health information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. We also may disclose health information to authorized federal officials so they may conduct special investigations and provide protection to the President, other authorized persons and foreign heads of state.

Coroners, Medical Examiners and Funeral Directors

We may release health information to a coroner, medical examiner or funeral director so that they can carry out their duties.

Inmates

If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information to the correctional institution or law enforcement official. This release would be if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

How to Learn About Special Protections For HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information

Special privacy protections apply to HIV-related information, alcohol and substance abuse information, mental health information and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact the Privacy Officer for more information about the protections.

Other Uses of Health Information

Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. This includes most uses and disclosures of psychotherapy notes, unless the disclosure is required by law and for other limited purposes. It also includes disclosure of your health information that would constitute a “sale” of the information, and includes use and disclosure of your health information for marketing purposes when the Plan is being paid by a third party to make the marketing communication. You may revoke your permission at any time by submitting a written request to our Privacy Officer, except to the extent that we acted in reliance on your permission.

Your Rights Regarding Health Information About You

You have the following rights, subject to certain limitations, regarding health information we maintain about you:

Right to Inspect and Copy

You have the right to inspect and copy health information that may be used to make decisions about your care or payment for your care. We may charge you a fee for the costs of copying, mailing or other supplies associated with your request. Upon request, we will provide you with an electronic copy of the health information that we maintain electronically.

Right to Request Amendments

If you believe that the health information we have is incorrect or that important information is missing, you may ask us to correct the records. This request, along with your reason, must be submitted in writing, to the Privacy Officer at the address provided at the end of this notice. You have the right to request an amendment for as long as the information is kept by or for the Plan. We may deny your request if we determine that the record is accurate.

Right to an Accounting of Disclosures

You have the right to request a list of other persons or organizations to whom we have disclosed your health information. The list does not include information about certain disclosures, including disclosures made to you or authorized by you, or disclosures for treatment, payment or operations. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list.

Right to Request Restrictions

You have the right to request a restriction or limitation on the health information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request, except for certain disclosures to health plans as noted below. If we agree, we will comply with your request unless we terminate our agreement or the information is needed to provide you with emergency treatment.

Right to Request Confidential Communications

You have the right to request that we communicate with you about medical matters in a more confidential way or at a certain location. For example, you can ask that we only contact you by mail or at work.

Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests, but we must grant reasonable requests if you tell us you would be in danger if we do not.

Right to Choose Someone to Act for You

You have the right to give someone medical power of attorney or, if someone if your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act before we take any action.

Right to Notification of a Breach of Your Health Information

If there is improper access, use or disclosure of your health information that meets the definition of a breach, we will notify you in writing.

Right to a Paper Copy of This Notice

ou have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time. You may obtain a copy of this Notice at our web site, www.montefiore.org.

How to Exercise Your Rights

To exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer at the address listed at the end of this Notice. To obtain a paper copy of our Notice, contact our Privacy Officer by phone or mail.

Changes to This Notice

We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for health information we already have as well as any health information we receive in the future. We will post a copy of the current Notice in the Human Re- sources office and on our website. The end of our Notice will contain the Notice’s effective date.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Plan or with the Secretary of the Department of Health and Human Services. To file a complaint with the Plan, contact our Privacy Officer at the address listed at the end of this notice. You will not be penalized for filing a complaint.

To file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, call 1.877.696.6775, or visit www.hhs.gov/ocr/privacy/hipaa/complaints/.

Questions

If you have a question about this Privacy Notice, please contact:

Privacy Officer
Montefiore Health System
555 South Broadway
Tarrytown, New York 10591
Phone: 718.920.8239
Email: privacyofficer@montefiore.org
Website: www.montefiore.org
Effective date: March 1, 2017

The Women’s Health and Cancer Rights Act is a federal law that provides protection for breast cancer patients who elect breast reconstruction in connection with a mastectomy. All group health plans, including HMOs, that provide medical and surgical benefits in connection with a mastectomy must also provide for reconstructive surgery, in a manner determined in consultation with the patient and attending physician.

If you or an enrolled dependent is a breast cancer patient, you should know that in addition to providing medical and surgical benefits in connection with a mastectomy, your Medical coverage also includes the following:

• Reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
  and
• Prostheses and treatment of physical complications at all stages of mastectomy, including lymphedemas.

This coverage is subject to applicable copays, annual deductibles and coinsurance provisions.