Privacy and Disclosures

PLEASE READ THE FOLLOWING IMPORTANT DISCLOSURE NOTICES.

• Disclosure - Small Groups
• Disclosure - Large Groups
• Other Disclosure Notices

 

PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

You may ask for an additional paper copy of this privacy notice at any time.

Para recibir esta noticia en español llame al 800-346-4643. >TTY 800-704-6370.*

In this notice, the words “us”,"our" and “we” mean Rocky Mountain Health Plans or RMHP. This includes plans underwritten by Rocky Mountain HMO, Inc. and Rocky Mountain HealthCare Options, Inc.

Q. Why is this notice provided?

A. Rocky Mountain Health Plans respects the privacy of your personal health information, also called PHI. By law, we have to make sure that your PHI is kept private. We must also give you this notice of our legal duties and privacy practices about your PHI.

Q. What is PHI?

A. PHI includes information that we have about your past, present, or future health or medical condition that could be used to identify you. It includes such things as health care treatment, or payment for health care you have received.

Q. How and when can you use, give out, or tell others about my PHI?

A. RMHP can use or give out your PHI:

 

• To help make sure your medical bills sent to us for payment are handled the right way.
• To help your doctors or other health care providers manage your health care, such as if you're in a wellness program or if you are a home health patient.
• To send you a reminder if you have a doctor's visit.
• To give you information about other health care treatments, services, and programs you may be interested in, such as a weight-loss program.
• To tell an employer that helps pay for your health benefits of your enrollment with RMHP.  Any PHI we might give to your employer group plan sponsor cannot be used for employment or benefit decisions.
• With other people who are with you at the time we discuss your PHI.  For example, when you allow others to be in the room when a home health nurse visits your home or if your spouse is with you on the phone when you call us. In these cases we may talk about your PHI with both of you.
• If you are injured or unconscious we may share PHI with your family or friends to help make sure you get the care you need and talk about how the care will be paid for.

Q. Are there state or federal laws that may call for RMHP to share your PHI?

A. Yes, there are also state and federal laws that may call for us to give your PHI to others. For example, we may give out your PHI: 

• To state and federal agencies that regulate us, such as the U.S. Department of Health and Human Services and the Colorado Division of Insurance.
• For public health activities. This may include reporting disease outbreaks.
• To public health agencies if we think there is a serious health or safety threat.
• For government health oversight activities, such as fraud investigations.
• To a court or administrative agency, such as to obey a court order.
• For law enforcement purposes, such as to find a suspect.
• To a government authority when there is abuse, neglect, or violence in the home.
• To a coroner, medical examiner, or funeral director to aid in deciding cause of death.
• For getting, saving, or transplanting organs, eyes, or tissue, and also in limited ways for research activities.
• For special government functions, such as for national safety.
• For job-related injuries because of state worker compensation laws.

If none of the above reasons apply, we must ask you to tell us in writing that we may use or give out your PHI before we do it.

If you tell us in writing that we may use or give out your PHI and change your mind, you may take back your written permission at any time. But you cannot take back your written permission if we already acted when we had it.

Q. What are my rights with respect to my PHI?

You have the right to ask that we limit how we use and give out your PHI. You also have the right to ask us to limit how much PHI we give to someone who is involved in your care or helping pay for your care. Please note that we do not have to agree to the request.

You have the right to ask that we talk with or write to you in a different way or at a different place to protect you from danger. For example, you may ask us to send your PHI to your work address instead of your home address.

You have the right to see and get a copy of your PHI. You may ask that we describe and tell you in writing about the PHI we have about you. We will respond to you within 30 days after we get your written request. If we deny your request, we will write you back with the reasons. We will also explain your right to have our denial reviewed. We may charge you a fee based on the cost of copying and postage or writing a description of PHI if that is what you asked for.

You have the right to get a list of times in which we have given out your PHI during the six years before your request. Please note that we are not required to give you a list of every time we gave out your PHI.

We do not have to tell you the times we gave out your PHI:

• Before April 14, 2003.
• For treatment, payment, and health care operation purposes.
• To you or others, if we have your written permission.
• To persons involved in your care or payment for care.
• For national safety reasons, or in special situations required by law enforcement or health oversight agencies.

We will act on your request within 60 days. Your first list will be free. We will give you one free list every 12 months if you ask for it. If you ask for another list within 12 months of getting your free list, we may charge you a fee.

You have the right to ask us to change your PHI or add missing information if you think there is a mistake in your PHI. We will respond within 60 days of getting your written request. If we deny your request, we will tell you the reasons in writing. Our written denial will also explain your right to file a written statement of disagreement. You can ask us to attach your request, our denial, and your statement of disagreement to your PHI anytime we give it out in the future.

Q. If I want to use these rights, do I have to make a written request?

A. Yes. All requests must be made in writing. You can get a request form by calling Customer Service line at 970-243-7050 or 800-346-4643. Send in your request to: Rocky Mountain Health Plans, PO Box 10600, Grand Junction, CO 81502-5600.

Q. How may I complain about RMHP's privacy practices?

A. Send your written complaint to RMHP Customer Service, Attn: Privacy, PO Box 10600, Grand Junction, CO 81502-5600. You also may complain to the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint about our privacy practices or for using any of the rights described in this notice.

Q. What other steps do we take to protect you PHI?

A. We limit access to your PHI to those who need it in order to help us provide products or services to you.  Other policies, such as limiting access to facilities, only discussing PHI in secure areas, keeping fax machines in secure areas, requiring passwords for computer access, and checking your identity before we discuss your PHI also help to protect your information.

Q. How will I know if my rights described in this notice change?

A. We follow the terms of the notice that is now in effect. This notice is effective as of July 1, 2012 . We reserve the right to change the terms of this notice and our privacy policies at any time. Then the new notice will apply to all your PHI. If we change this notice, we will put the new notice on our website and mail a copy of the new notice to our subscribers.

Q. Who should I contact to get more information, or to get a copy of this notice?

A. You can do this in one of three ways: 

• Visit our website: www.rmhp.org.
• Write to us: Rocky Mountain Health Plans, PO Box 10600, Grand Junction, CO 81502-5600.
• Call Rocky Mountain Customer Service: 970-243-7050 or 800-346-4643.

DISCLOSURE NOTICE FOR SMALL EMPLOYER GROUPS 

Plans underwritten by Rocky Mountain HMO (RMHMO) or Rocky Mountain HealthCare Options, Inc. (RMHCO)

Class of Business

Your group will be included in the Small Employer class and will not be considered part of a separate class of business. This class is comprised of small employer groups with up to 50 eligible employees and includes qualified Business Groups of One.

Rates

Rates are established on a community basis in which medical and administrative costs for all small employer groups are computed and trended forward for expected increases due to inflation and utilization. Rates are not adjusted based on duration of coverage of the group’s employees or its employees’ dependents. An index rate is established and adjusted for the level of benefits contained in your plan. Case characteristics that may be used by RMHP for your specific group that may affect your group’s rates are your enrolled employees’ ages, family size, and your company’s geographic location and industrial classification.

• You will have higher premiums for older employees.
• Your premiums will vary depending on your employees’ family size.
• You will have higher premiums if your company is located in an area of high medical costs.
• We may further adjust your premiums depending on your Standard Industrial Classification (SIC).
• You may have higher health status premium adjustments based on health status in some cases if your group had health benefit coverage that was self-insured or through a non-small group plan within the past 12 months.

Premium rate changes, including changes to case characteristics factors, are generally made on your group’s anniversary date, but Rocky Mountain Health Plans (RMHP) has the right to change premium rates more frequently. You will get 30 days’ prior written notice before any premium change goes into effect. Premium rates will also change as described in the premium rate schedule in your Group Service Agreement. Additional rate adjustments will be made for any benefit changes made to your plan. A rate quote for all small group products being marketed by RMHP in Colorado will be provided within five working days of an employer’s oral or written request.

Premium Rating Options

Small employers with 10 to 50 eligible employees have a choice of four-tier composite rates or four-tier age-banded rates and can request both to compare the two rating approaches. In either case, the total monthly premium to the employer is identical.

Small employers with less than 10 eligible employees are offered only four-tier age-banded rates.

 

• Age-banded rates means that you will be billed different premiums based on employees’ ages. For example, the premium for a 60-year-old employee would be substantially higher than for a 20-year-old employee. Age-banded rates are always billed in four-tier monthly premiums (employee; employee and spouse; employee and children; and employee, spouse, and children).
• Composite rates do not vary because of age of the employee. In the example given above, both the 60- and 20-year-old employees would have the same monthly premium rate. Composite rates are available in four-tier.

Access Plans

An access plan is available upon request to any interested party for each managed care network offered by RMHP. Such access plans contain information on providers, hospitals, referral and grievance procedures, quality assurance, access for members with special needs, emergency coverage provisions, and other information on how to access services.

Geographic Areas Served

Upon request, we will provide you or any enrollee a description of the geographic areas served by Rocky Mountain Health Plans.

Benefits and Premiums

Information about benefits for all the health benefit plans you requested or for which you qualify is enclosed. If you have provided us sufficient information to determine premiums for your group, such premium information is also included. Colorado law requires carriers to make available a Colorado Health Benefit Plan Description Form, which is intended to facilitate comparison of health plans. The form must be provided automatically within three (3) business days to a potential policyholder who has expressed interest in a particular plan or who has selected the plan as a finalist from which the ultimate selection will be made. The carrier also must provide the form, upon oral or written request, within three (3) business days to any person who is interested in coverage under or who is covered by a health benefit plan of the carrier.

Basic Health Benefit Plan Coverage

For those persons interested in an RMHMO HMO Basic Limited Mandate Health Benefit Plan for Colorado or an RMHCO PPO Basic Limited Mandate Health Benefit Plan for Colorado, note the following: Interested policyholders, certificate holders, and enrollees are hereby given notice that this small group policy does not cover all the health services and benefits, specifically non-biologically based mental health services, alcoholism, and dental anesthesia for children, which the Colorado Revised Statutes usually require group plans to cover.

 

Pre-Existing Condition Limitations

The pre-existing condition limitation period does not apply to the RMHMO HMO Basic Limited Mandate Health Benefit Plan for Colorado and the RMHMO HMO Standard Health Benefit Plan for Colorado. It also does not apply to pregnancy, a newborn child, a newly adopted child, a child placed for adoption, or to a child who is under 19 years of age.

RMHP will impose a six-month pre-existing condition limitation period (12-month limitation period for Business Groups of One) for all new enrollees (not including late enrollees) who have a physical or mental condition for which medical advice, diagnosis, care, supplies, prescription drugs, or treatment was recommended or received within six months immediately preceding the date of their enrollment in an RMHP plan or the first day of any employer-imposed waiting period, whichever is earlier. This means that if you have a medical condition before enrolling in our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. The pre-existing condition limitation period will be reduced by the period of time that a new enrollee was covered by creditable coverage, provided the creditable coverage did not terminate more than 90 days before the earlier of the first day of the waiting period or the effective date of coverage under an RMHP plan. Such health coverage policies or plans that count as "creditable coverage" can reduce the length of any pre-existing condition limitation period that might otherwise apply by the number of days of your prior creditable coverage. Most prior health coverage is creditable coverage and can be used to reduce the pre-existing condition exclusion limitation if you have not had a break in coverage of at least 90 days.

RMHP will impose an 18-month pre-existing condition limitation period for all late enrollees who have a physical or mental condition for which medical advice, diagnosis, care, supplies, prescription drugs, or treatment was recommended or received within six months immediately preceding the date of their enrollment in an RMHP plan. This 18-month period shall also include a 12-month or less period of exclusion from coverage that is applicable to late enrollees. The pre-existing condition limitation period for late enrollees will be reduced by the period of time that the late enrollee was covered by creditable coverage, provided the creditable coverage did not terminate more than 90 days before the date of their enrollment under an RMHP plan.

Your Group's Right to Renew

Your group may renew its coverage for successive one-year periods. Your group may terminate the agreement by giving RMHP written notice of intent to terminate. RMHP must receive such written notice no later than 5:00 p.m. Mountain Time on the first business day of the month following the termination effective date; otherwise, the effective date of termination shall be the end of the next calendar month.

RMHP shall not discontinue coverage or refuse to renew a plan except for the following reasons:

 

• Nonpayment of required premiums.
• Fraud or intentional misrepresentation of material fact by the group or with respect to coverage of an individual or fraud or intentional misrepresentation of material fact by the individual or the individual’s representative.
• RMHP elects to nonrenew and discontinue offering all its small group health care plans delivered or issued in the State of Colorado
• The group fails to comply with participation or contribution requirements.
• There is no longer any member who is a group enrollee who lives, resides, or works in the service area.
• The group is no longer actively engaged in the business in which it was engaged on the effective date of the Group Service Agreement.
• An employer that is provided coverage through one or more bonafide associations ceases to belong to that association(s).
• Any other reason for which state or federal law permits nonrenewal of the Group Service Agreement.

Mandated Benefit Cost

Small employers purchasing any health benefit plan other than a basic plan must pay for all of the mandated benefitsThe premium for this plan includes the cost of these mandated benefits, specifically: coverages for newborn, maternity, pregnancy, childbirth, complications from pregnancy and childbirth, therapies for congenital defects and birth abnormalities, low-dose mammography, mental illness, biologically-based mental illness, the availability of alcoholism treatment, the availability of hospice care, prostate cancer screening, child health supervision, hospitalization and general anesthesia for dental procedures for dependent children, early intervention services, diabetes, prosthetic devices, and hearing aids for minors. pursuant to section 10-16-104.

COLORADO INSURANCE LAW REQUIRES ALL CARRIERS IN THE SMALL GROUP MARKET TO ISSUE ANY HEALTH BENEFIT PLAN IT MARKETS IN COLORADO TO SMALL EMPLOYERS OF 2-50 EMPLOYEES, INCLUDING A BASIC OR STANDARD HEALTH BENEFIT PLAN, UPON THE REQUEST OF A SMALL EMPLOYER TO THE ENTIRE SMALL GROUP, REGARDLESS OF THE HEALTH STATUS OF ANY OF THE INDIVIDUALS IN THE GROUP. BUSINESS GROUPS OF ONE CANNOT BE REJECTED UNDER A BASIC OR STANDARD HEALTH BENEFIT PLAN DURING OPEN ENROLLMENT PERIODS AS SPECIFIED BY LAW.

The disclosure statements in this form are required by Colorado law and are not intended to be a full description of all plan requirements. The complete provisions of the plan(s), including detailed description of benefits, exclusions, and limitations, can be found in the Group Service Agreement and the Evidence of Coverage.

MK57 - Revised 2010

Click here for a printable version of this disclosure.

DISCLOSURE NOTICE FOR LARGE EMPLOYER GROUPS

Access Plans

An access plan is available upon request to any interested party for each managed care network offered by RMHP. Such access plans contain information on providers, hospitals, referral and grievance procedures, quality assurance, access for members with special needs, emergency coverage provisions, and other information on how to access services.

Geographic Areas Served

Upon request, we will provide you or any enrollee a description of the geographic areas served by Rocky Mountain Health Plans.

Your Group’s Right to Renew

Your group may renew its coverage for successive one-year periods. Your group may terminate the agreement by giving RMHP written notice of intent to terminate. RMHP must receive such written notice no later than 5:00 p.m. Mountain Time on the first business day of the month following the termination effective date; otherwise, the effective date of termination shall be the end of the next calendar month.

Colorado law requires carriers to make available a Colorado Health Plan Description Form, which is intended to facilitate comparison of health plans. The form must be provided automatically within three (3) business days to a potential policyholder who has expressed interest in a particular plan or who has selected the plan as a finalist from which the ultimate selection will be made. The carrier also must provide the form, upon oral or written request, within three (3) business days to any person who is interested in coverage under or who is covered by a health benefit plan of the carrier.

The disclosure statements on this form are required by Colorado law and are not intended to be a full description of all plan requirements. The complete provisions of the plan(s), including detailed description of benefits, exclusions, and limitations, can be found in the Group Service Agreement and the Health Benefits Contract.

MK298R1005 - Revised October, 2005

Click here for a printable version of this disclosure.

EQUAL OPPORTUNITY POLICY STATEMENT

This policy is available on tape in Human Resources.

It is the policy of Rocky Mountain Health Plans (RMHP) to provide equal opportunity and to prevent discrimination based on race, color, national origin, age, or disability in admission or access to, or treatment or employment in, RMHP programs, health care plans, and activities to the extent required by applicable law.

All federally funded benefits and services are provided in accordance with Title VI of the Civil Rights Act, as amended, Section 504 of the Rehabilitation Act, as amended, the Age Discrimination Act of 1975, as amended, the Americans with Disabilities Act of 1990, as amended, as well as other related laws. All subcontractors are notified of their responsibility to comply with these laws.

The EEO Officer is responsible for compliance with state and federal equal opportunity laws. She is also responsible for implementing the Equal Opportunity Plan. If you would like more information regarding these provisions, or if you believe you have not been treated in accordance with this policy, please contact the Member Concerns Coordinator at 800-346-4643, 970-243-7050, or TTY 800-704-6370 or 970-248-5019; para asistencia en español llame al 800-346-4643.

MEDICARE DISCLAIMERS

Network Providers

You can use any doctor who is part of the Rocky Mountain Health Plans' network. You may also go to doctors outside of our network. We may not pay for services you receive outside of our network, but Medicare will pay for its share of charges it approves. You will be responsible for paying the Medicare deductible and coinsurance for those services, unless they were authorized in advance by RMHP.

If you reside in one of the following Colorado counties you are required to use certain providers for mental health care to be covered by RMHP. These providers are listed in the Provider directory with a network listing of Life Strategies:

• Adams, Arapahoe, Bent, Boulder, Broomfield, Chaffee, Cheyenne, Clear Creek, Conejos, Costilla, Crowley, Custer, Denver, Douglas, Elbert, El Paso, Fremont, Gilpin, Hinsdale, Huerfano, Jefferson, Kiowa, Kit Carson, Larimer, Las Animas, Lincoln, Logan, Morgan, Otero, Park, Phillips, Prowers, Pueblo, Rio Grande, Saguache, Sedgwick, Teller, Washington, Weld and Yuma counties.

Enrollment, Premiums and Benefits

RMHP’s contract with Medicare is renewed annually. The availability of coverage beyond the end of the current contract year is not guaranteed. However, RMHP has contracted with Medicare to provide benefits since 1977.

Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change each year on January 1.

Optional supplemental benefit packages may change each year on January 1.

Benefits may be subject to copayments, limitations and/or restrictions. See the Evidence of Coverage or contact Customer Service for details.

Eligible beneficiaries can enroll in RMHP Medical-only Cost plans at any time but can only enroll in plans that include Part D drug coverage during specific times of the year. For enrollment guidelines and full information on RMHP benefits, please call Customer Service at 888-282-1420 toll free or 970-244-7912 (TTY: 711), 8:00 a.m. to 8:00 p.m., Mountain Time, (from October 1 - February 14, 7 days per week; from February 15 - September 30, M-F) . Para asistencia en español llame al 888-282-1420. 

RMHP is a Medicare-approved Cost plan.

Medicare beneficiaries may be enrolled in only one Part D plan at a time.

Individuals are able to enroll in RMHP if they are enrolled under Medicare Parts A and B or B only and reside in our service area.

In addition to the applicable RMHP plan premium, Members continue to pay the Original Medicare Part B premium.

If you decide to switch to premium withhold through Social Security or move from premium withhold to direct bill, it could take up to three months for it take effect and you will continue to be responsible for direct payment of premiums until the change takes effect.

Information is available in alternative formats such as large print and Braille.

For more information, contact Customer Service at 888-282-1420 toll free (TTY: 711), 8:00 a.m. to 8:00 p.m., Mountain Time, 7 days a week. Para asistencia en español llame al 888-282-1420.