Required Notices and Disclosures (Including HIPAA Notice of Privacy Rights)

In the following section, you will find these important notices that describe your rights and protections. Included are: 

• Patient Protection Act
• Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Rights - Updated February 1st, 2026
• Medicare Part D – Notice of Creditable Coverage
• Newborns’ and Mothers’ Health Protection Act  
• Women’s Health and Cancer Rights Act
• Children’s Health Insurance Program (CHIP)
• COBRA Notice

Patient Protection Act 

The intent of the Patient Protection Act is to ensure, among other things, that patients and providers are informed about their health insurance plans. This section outlines some important terms and conditions. (Note: Kaiser Permanente is subject to the same law. Contact Kaiser for the details of its Patient Protection provisions.)

1. What are an Enrollee’s rights and responsibilities?  Enrollees have the right to be treated with respect and recognition of their dignity and need for privacy 

• Have access to urgent and emergency services, 24 hours a day, seven days a week
• Know what their rights and responsibilities are. Members will be given information about their health plan and how to use it and about the providers who will care for them. This information will be provided in a way that members can understand.
• Participate in decision-making regarding their health care. This includes a discussion of appropriate or medically necessary treatment options for their conditions, whether or not the cost is covered under the plan, and the right to refuse care and be advised of the medical result of their refusal.
• Receive services as described in their plan handbooks  Have their medical and personal information remain private. Personal information will be handled in compliance with state and federal law and will be given to third parties only as necessary to administer the plan, as required by law, or as permitted by the member.
• File a complaint or appeal about any aspect of the plan and to receive a timely response. Members are welcome to make suggestions to Moda Health, the plan administrator.
• Obtain free language assistance services, including verbal interpretation services, when communicating with Moda Health, the plan administrator.
• Have a statement of wishes for treatment, known as an Advance Directive, on file with their professional providers. Members also have the right to file a power of attorney which allows the 140 member to give someone else the right to make health care choices when the member is unable to make these decisions.

Members have the responsibility to:

• Read the plan handbook to make sure they understand the Plan. Members are advised to call Medical Customer Service or Pharmacy Medication Benefit Customer Service with any questions.
• Treat all physicians and providers and their staff with courtesy and respect
• Provide all the information needed for their physician or provider to provide good health care
• Participate in making decisions about their medical care and forming a treatment plan
• Follow instructions for care they have agreed to with their physician or provider
• Use urgent and emergency services appropriately
• Present their medical identification card when seeking medical care
• Notify physicians and providers of any other insurance policies that may provide coverage
• Reimburse the Plan from any third-party payments you may receive
• Keep appointments and be on time. If this is not possible, members must call ahead to let the provider know they will be late or cannot keep their appointment.
• Seek regular health checkups and preventive services  Provide adequate information to the plan to properly administer benefits and resolve any issues or concerns that may arise

Members may call the Moda Health’s Customer Department for questions about these rights and responsibilities. 

2. What do I do if I have a medical emergency? If you believe you have a medical emergency, you should call 9-1-1 or seek care from the nearest appropriate physician or provider, such as a physician’s office or clinic, urgent care facility or emergency room.
3. How will I know if benefits are changed or terminated? It is the responsibility of your employer to notify you of benefit changes or termination of coverage. If your Group contract terminates and your employer does not replace the coverage with another group contract, your employer is required by law to inform you in writing of the termination.
4. If I am not satisfied with my health plan, how do I file an appeal? You can file an appeal by contacting Moda Health’s Customer Service or by writing a letter to Moda Health (P.O. Box 40384, Portland, Oregon 97240). See the booklet section titled “Appeals” for complete information. You may also contact the Oregon Division of Financial Regulation:

By phone: 503-947-7984 or 1-888-877-4894

By mail: Oregon Division of Financial Regulation P.O. Box 14480 Salem, Oregon 97309-0405

Online: www.dfr.oregon.gov

By email: cp.ins@state.or.us 

5. What are Moda Health’s prior authorization and utilization review criteria? 

Prior authorization is the process Moda Health uses to determine whether a service is covered under the Plan (including whether it is medically necessary) prior to the service being rendered. Members may contact Moda Health’s Customer Service Department, visit their Member Dashboard, or review the CityCore, CityNet, CityBasic CityHDP and CityHD medical plan prior authorization section in this booklet to request information on the list of services that require prior authorization. Many types of treatment may be available for certain conditions; the prior authorization process helps determine which treatment is covered under the Plan. 

Obtaining a prior authorization is your assurance that the services and supplies recommended by your provider are medically necessary and covered under your health plan. Except in the case of fraud or misrepresentation, prior authorization for benefit coverage and medical necessity shall be binding if obtained no more than 30 days prior to the date the service is provided, and prior authorization for member eligibility shall be binding if obtained no more than five business days prior to the date the service is provided. Utilization review is the process of reviewing services after they are rendered to ensure that they were medically necessary and appropriate with regard to widely accepted standards of good medical practice. 

For a written summary of information that may be included in the Moda Health utilization review of a particular condition or disease, call Moda Health’s Customer Service.

6. How are important documents, such as my medical records, kept confidential? Moda Health protects your information in several ways:

• Moda Health has a written policy to protect the confidentiality of health information
• Only employees who need to access your information in order to perform their job functions are allowed to do so
• Disclosure outside Moda Health is permitted only when necessary to perform functions related to providing coverage and/or when otherwise allowed by law
• Most documentation is stored securely in electronic files with designated access

7. How can non-English-speaking members get information about the plan? 

A representative will coordinate the services of an interpreter over the phone when a member calls.

8. What additional information can I get upon request? 

The following documents are available by calling Moda Health’s Customer Service:

• A copy of Moda Health’s annual report on complaints and appeals
• A description of Moda Health’s efforts to monitor and improve the quality of health services
• Information about procedures for credentialing network providers and how to obtain the names, qualifications, and titles of the providers responsible for a member’s care
• Information about Moda Health’s prior authorization and utilization review procedures

9. What information about Moda Health is available from the Oregon Division of Financial Regulation? The following information regarding the Moda Health benefit plans is available from the Oregon Division of Financial Regulation:

• The results of all publicly available accreditation surveys
• A summary of Moda Health’s health promotion and disease prevention activities
• An annual summary of appeals 142  An annual summary of utilization review policies
• An annual summary of quality assessment activities
• An annual summary of scope of network and accessibility of services

Contact: 

Oregon Division of Financial Regulation 

P.O. Box 14480 

Salem, Oregon 

97309-0405

 503-947-7984 or toll-free at 1-888-877-4894

Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Rights

Effective September 23, 2013

The Plan is in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Certification of creditable coverage will be provided to plan participants pursuant to this act and to relevant administrative rules.

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

Introduction

The Plan has a health care component (the “Health Plan”) subject to HIPAA. The Health Plan includes medical (including prescription coverage), dental, vision, and certain employee assistance programs. This Notice of Privacy Practices (“Notice”) is required by HIPAA.

If you are enrolled in any of the Health Plan’s insured coverage options, you may receive a separate privacy notice from your insurer or HMO. The privacy of your personal health information (“PHI”) that is created, used, or disclosed by the Health Plan is protected by HIPAA. By law, the Health Plan is required to:

• Maintain the privacy of your protected health information;
• Provide you with this Notice of the Health Plan’s legal duties and privacy practices with respect to your protected health information;
• Notify you if there is a breach of your unsecured protected health information; and
• Abide by the terms of this Notice

Protected health information is information that identifies you and either relates to your physical or mental health condition, the provisions of health care, or relates to the payment of your health care expenses health information and is created, received, or maintained by the Health Plan. However, protected health information does not include all health information that may be maintained by the City or its benefit plans. For example, protected health information does not include health information that is used or maintained by the City’s non-health benefit plans, such as life insurance. Protected health information also does not include any health information that was obtained by the City in its capacity as an employer (e.g., through an FMLA or leave of absence request). If health information is not protected health information, then the health information is not protected by HIPAA and is not covered by this Notice. 

The City and the Health Plan understand that your protected health information is personal and private, and both are committed to maintaining the privacy of your protected health information. This Notice summarizes the Health Plan’s and City’s privacy practices and those of any third party that assists in the administration of the Health Plan. In particular, this notice describes how the Health Plan may use or disclose your protected health information. It also describes the Health Plan’s obligations to you and your individual rights regarding the use and disclosure of your protected health information. Please review it carefully.

The Health Plan reserves the right to change, at any time, its privacy practices and the terms of this notice and to make the new notice effective for all protected health information. Once revised, information about any material revision (or a revised copy of the Notice) will be delivered to you, within 60 days of the revision and the notice will be posted on the City’s Web site at https://www.portland.gov/bhr. You may also request the new notice be mailed to you.

How the City Uses this Information

The City acquires limited protected health information about you in order to enroll, maintain, change and terminate your participation in the Plans. Those in the City performing these functions include City payroll employees in your bureau, employees in the Bureau of Technology Services (BTS), and employees assigned to the Health & Financial Benefits Office in the Bureau of Human Resources. They will obtain the following information from you to perform these functions: The names, dates of birth, addresses, phone numbers, social security numbers, and employment data with the City, enrollment in other medical benefit plans if any, of yourself and any dependents and/or domestic partners that participate in the Plans. Other authorized City employees may also use this information to conduct quality assessment and improvement activities, other activities relating to the creation, renewal or replacement of health benefits and budget creation and analysis.

The City may also acquire information from the Plans that has been de-identified—that is medical information that cannot be linked to any individual participant, for purposes of utilization review, cost studies, and review of appeals decisions made by the Health Plan with respect to any Plan benefit.

How the Health Plan Uses and Shares Information

The Health Plan use protected health information and may share it with others as part of your treatment, payment for treatment, and Plan operations. The following are ways the Health Plan may use or share information about you:

• The Health Plan will use the information to administer your plan benefits and help pay your medical bills that have been submitted to the Health Plan by doctors and hospitals for payment
• The Health Plan may share your information with your doctors or hospitals to help them provide medical care to you. For example, if you are in the hospital, the Health Plan may provide access to any medical records sent to the Health Plan by your doctor.
• The Health Plan may use or share your information with others to help manage your health care. For example, the Health Plan might talk to your doctor to suggest a disease management or wellness program that could help improve your health.
• The Health Plan may share your information with individuals who perform business functions for the City. The City will only share your information if there is a business need to do so and if our business partner agrees to protect the information, in accordance with this privacy notice.
• The Health Plan may give you information about treatments and programs or about health-related products and services that may be to your benefit. For example, the Health Plan sometimes send out letters to notify you about chronic conditions, tobacco cessation or nutrition programs.
• The Health Plan may use and disclose your protected health information for administration and operations, including quality assessment and quality improvement activities; underwriting (excluding any protected health information that is genetic information), premium rating and other activities relating to the creation, renewal or replacement of a health insurance or health benefits contract or a stop-loss or excess-loss insurance contract; conducting or arranging for medical assessments, legal services and auditing functions (including fraud and abuse detection and compliance programs), and other general administrative activities such as customer service and HIPAA compliance. For example, the Health Plan may disclose your health information to potential health insurance carriers in order to obtain a premium bid from the carrier.

There are other situations in which the Health Plan may disclose your protected health information without your authorization.

• The Health Plan may disclose your protected health information to you or your personal representative
• The Health Plan may disclose protected health information to a close friend or family member involved in or who helps pay for your health care. The Health Plan may also advise a family member or close friend about your condition, your location (for example, that you are in the hospital), or death, unless other laws would prohibit such disclosures. If you are present or otherwise available before the use or disclosure, the Health Plan may make the use or disclosure if the Health Plan obtains your agreement; provides you with an opportunity to object and you do not object; or reasonably infers from the circumstances, through the exercise of professional judgment, that you do not object. If you are not present or the opportunity to agree or object to the use or disclosure of your protected health information is not practical due to your incapacity or an emergency situation, the Health Plan may, through the exercise of professional judgment, determine whether the disclosure is in your best interest. Any disclosure made under these circumstances will be limited to the protected health information which is directly related to the person’s involvement with your care or payment for your health care or need for notification.
• The Health Plan, or an insurer of benefits provided under the Health Plan, may disclose your protected health information without your written authorization to designated personnel at your employer for plan administration purposes. The employer agrees not to use or disclose your health information other than as permitted or required by the plan document(s) for the Health Plan and by applicable law. In particular, your health information that is protected health information will not be used for employment decisions.
• Certain services are provided to the Health Plan by third-party administrators known as “business associates.” For example, the Health Plan may place information about your health care treatment into an electronic claims processing system maintained by a business associate so that your claim may be paid. In so doing, the Health Plan will disclose your protected health information to its business associates so that the business associates can perform their claims payment functions. However, the Health Plan will require its business associates, through written agreements, to appropriately safeguard your health information.

There are also state and federal laws that may require the Health Plan to release your health information to others. The Health Plan may be required by law to provide information to others for the following reasons: 

• The Health Plan may have to give information to law enforcement agencies. For example, the Health Plan is required to report when child abuse or neglect or domestic violence is reasonably believed to have occurred.
• The Health Plan may be required by a court or administrative agency to provide information because of a search warrant or subpoena
• The Health Plan may report health information to public health agencies to report births or deaths or if the Health Plan believes there is a serious health or safety threat
• The Health Plan may report health information on job-related injuries because of requirements of state or other workers’ compensation laws
• The Health Plan may report information to the Food and Drug Administration. This agency is responsible for investigating or tracking prescription medication and medical device problems.
• The Health Plan may have to report information to state and federal agencies that regulate the City, such as the U.S. Department of Health and Human Services to enable the Secretary to investigate and determine the Health Plan’s compliance with HIPAA.
• The Health Plan may disclose your protected health information to a coroner or medical examiner for identification purposes, for determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. The Health Plan may also disclose protected health information to a funeral director, as necessary to allow the funeral director to carry out their duties.
• If you are an organ donor, the Health Plan may disclose your protected health information as necessary to facilitate organ or tissue donation, including transplantation
• The Health Plan may disclose your protected health information to researchers without your authorization if their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information and the researchers have provided certain necessary representations regarding the research.
• When the appropriate conditions apply and if you are a member of the Armed Forces, the Health Plan may disclose your protected health information (1) for activities deemed necessary by appropriate military command authorities, (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to a foreign military authority if you are a member of that foreign military service. The Health Plan may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities for the conduct of lawful intelligence, counterintelligence and national security activities. The Health Plan may also disclose protected health information to authorized federal officials for the provision of protective services to the President or others that are authorized by law.
• If you are an inmate of a correctional institution or in the custody of a law enforcement official, the Health Plan may disclose your protected health information to the institution or official if the information is necessary for (1) the provision of health care to you, (2) your health and safety or the health and safety of other inmates, the officers, employees, or others at the correctional institution, (3) law enforcement on the premises of the correctional institution, or (4) the safety and security of the correctional institution.
• The Health Plan may disclose your protected health information, in certain situations, to law enforcement officials, including: (1) when directed by a court order, subpoena, warrant, summons or similar process; (2) if necessary to identify or locate a suspect, fugitive, material witness or missing person; and (3) if necessary to report information about the victim of a crime in limited circumstances where the victim is unable to provide consent.
• The Health Plan will disclose your protected health information where required to do so by federal, state or local law

If the Health Plan uses or discloses your information for any reasons other than the above, your written authorization will be obtained first. The Health Plan is required to obtain your written authorization as a condition for:

• Any use or disclosure of your protected health information for marketing purposes, except if the communication is in the form of face-to-face communications with you or a promotional gift of nominal value;
• Any use or disclosure of your protected health information that is in the form of a sale of protected health information; or
• Any use or disclosure of psychotherapy notes, except to carry out certain treatment, payment or health care operations, or as otherwise required by law

If you give the Health Plan written permission and change your mind, you may revoke your written authorization at any time. The Health Plan will honor the revocation except to the extent that the Health Plan has already relied on your authorization.

Note: If the Health Plan discloses information as a result of your written authorization, it may be re-disclosed by the receiving party and may no longer be protected by state and federal privacy rules. However, federal or state law may restrict re-disclosure of additional information such as HIV/AIDS information, mental health information, genetic information and drug/alcohol diagnosis, treatment, or referral information. 

Substance Use Disorder Records (42 C.F.R. Part 2)

To the extent protected by law, participants' substance use disorder treatment records held by the Plan(s) cannot be used to investigate or prosecute the patient without written patient consent or a court order after you are presented with notice and an opportunity to be heard as provided for in 42 C.F.R. Part 2. You can provide a single consent for all future uses and disclosures of such records for purposes of treatment, payment, and health care operations that does not permit use for civil, criminal, administrative, or legislative proceedings.

What Are Your Rights

You have certain rights with respect to your protected health information. These include: 

• You have the right to ask the Health Plan to restrict how your information is used or disclosed for treatment, payment, or health care operations. You also have the right to ask the Health Plan to restrict information provided to persons involved in your care. While the Health Plan may honor your request for restrictions, they are not required to agree to these restrictions.
• You have the right to submit special instructions to the Health Plan regarding how information is sent to you that contains protected health information. For example, you may request that your information be sent by a specific means (for example, U.S. mail only) or to a specific address. The Health Plan will accommodate reasonable requests by you as explained above. The Health Plan may require that you make your request in writing.
• You have the right to inspect and obtain a copy of information that the Health Plan maintain about you in a designated record set. However, you may not be permitted to inspect or obtain a copy of information that is:
  • Contained in psychotherapy notes;
  • Compiled in reasonable anticipation of, or for use in a civil, criminal, or administrative action or proceeding; and
  • Subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. 263a, to the extent the provisions of access to the individual would be prohibited by law or exempt from the Clinical Laboratory Improvements Amendments of 1988, pursuant to 42 CFR 493.3(a)(2)
• You also have the right to request that a copy of your protected health information that the Health Plan maintains electronically be provided to you in a specified electronic form and format. If the requested electronic form and format is not readily producible, the Health Plan will provide the copy in a readable electronic form and format to which you agree. You may request an electronic copy of your health information if it is maintained in an electronic health record. You may also request that such electronic health information be sent to another entity or person, so long as that request is clear, conspicuous and specific. Any charge that is assessed to you for these copies, if any must be reasonable and based on the Health Plan’s cost.

Additionally, in certain situations the Health Plan may deny your request to inspect or obtain a copy of your information. If the Health Plan denies your request, the Health Plan will notify you in writing. Any denial will explain your right to have the denial reviewed. 

The Health Plan may require that your request be made in writing. The Health Plan will respond to your request no later than 30 days after it is received. If the information you request is not maintained or accessible to the Health Plan on-site, the Health Plans will respond to your request no later than 60 days after it is received. If additional time is needed, the Health Plan will inform you of the reasons for the delay and the date that the Health Plan’s action on your request will be completed. 

If you request a copy, a reasonable fee based on copying and postage costs will be required. You may request a copy of the portion of your enrollment and claim record related to an appeal free of charge.

• You have the right to ask the Health Plan to amend information maintained about you in a designated record set. The Health Plan will require that your request be in writing and that you provide a reason for your request. The Health Plan will respond to your request no later than 60 days after it is received. If a response cannot be made within 60 days, the time may be extended by no more than an additional 30 days. If additional time is needed, you will be notified of the delay and the date by which action on your request will be completed. 

If an amendment is made you will be notified that it was made, and the Health Plan will obtain your authorization to notify the relevant persons you have identified with whom the amendment needs to be shared. The Health Plan will notify these persons, including their business associates, if any, of the amendment. 

If your request to amend is denied, you will be notified in writing of the reasons for the denial. The denial will explain your right to file a written statement of disagreement. The Health Plan has a right to rebut your statement. However, you have the right to request that your written request, the Health Plan’s written denial, and your statement of disagreement be included with your information for any future disclosures.

• You have the right to receive an accounting of certain disclosures of your information made by the Health Plan during the six years prior to your request. The accounting may not include certain disclosures, including:
  • For treatment, payment, and health care operations purposes;
  • Made for you;
  • Made in connection with a use or disclosure otherwise permitted;
  • Made pursuant to your authorization;
  • For a facility’s directory or to persons involved in your care or other notification purposes;
  • For national security or intelligence purposes;
  • To correctional institutions, law enforcement officials; or
  • Made as part of a limited data set for research, public health, or health care operations purposes

Additionally, if the Health Plan discloses your information for research purposes pursuant to an authorization, the Health Plan may not account for each disclosure of your information. Instead, the Health Plan will provide for you: (1) the name of the research protocol or activity; (2) a description of the research protocol or activity including the purpose for the research and the criteria for selecting particular records; (3) a description of the type of Protected Health Information that was disclosed; (4) the date or period of time when such disclosure occurred; and (5) the name, address, and telephone number of the entity that sponsored the research and researcher to whom the information was disclosed. 

The Health Plan will act on your request for an accounting within 60 days. Additional time may be needed to act on your request and may therefore take up to an additional 30 days. Your first accounting will be free, and you will be entitled to one free accounting upon request every 12 months. However, if you request an additional accounting within 12 months of receiving a free accounting, you will be charged a fee. You will be informed of the fee in advance, and you will be provided with an opportunity to withdraw or modify your request. 

Exercising Your Rights

You have a right to receive a paper copy of this notice upon request at any time. You can also view a copy of the notice on our Web site at https://www.portland.gov/bhr. 

If you have any questions about this notice or privacy practices of the City or the Health Plan, please contact the HIPAA Officer at 503-823-3506. Our office is open Monday through Friday from 8 a.m. to 5 p.m.

If you believe your privacy rights have been violated by the Health Plan you may file a complaint with the City by writing the City at the address as follows:

Tracy Warren
City of Portland Privacy Officer
Bureau of Human Resources
City of Portland, Oregon
1120 SW 5^th Avenue, Room 987
Portland, Oregon 97204
Phone: 503-823-3572
Fax: 503-823-3288
Email: tracy.warren@portlandoregon.gov            

You may also notify the Office of Civil Rights, U.S. Department of Health and Human Services of your complaint. The City cannot and will not take any action against you for filing a complaint. You may contact the Office of Civil Rights at:

Office for Civil Rights
U.S. Department of Health and Human Services
Room 509F, HHH Building
200 Independence Avenue, S.W.
Washington, DC 20201
OCR Hotlines-Voice: 1-800-368-1019
Ocrmail@hhs.gov

The complaint should generally be filed within 180 days of when the act or omission complained of occurred.

Important Notice from the City of Portland 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 the City of Portland 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: 

1. 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.
2. The City of Portland has determined that the prescription drug coverage offered by the CityCore, CityNet, CityHDP and CityHD and Kaiser Plans 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-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, your current City of Portland coverage will not be affected. The City of Portland plan’s coverage will be primary and pay before Medicare.

For retirees and spouses of retirees: if you do decide to join a Medicare drug plan and drop your current City of Portland coverage, be aware that you and your dependents will not be able to get this coverage back. 

For active employees and spouses of active employees: if you do decide to join a Medicare drug plan and drop your current City of Portland coverage, be aware that you and your dependents will not be able to get this coverage back until the next open enrollment period (unless you experience a qualified family status change).

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 the City of Portland 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 19 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 Your Current Prescription Drug Coverage
Contact the Benefit Information Line at 503-823-6031 for further information. 

Note: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the City of Portland changes. You also may request a copy of this notice 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 in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. 

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of 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.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

                        Date:                                  July 1, 2025

                        Name of Entity/Sender:       City of Portland
                        Contact--Position/Office:     Health & Financial Benefits Office 
                        Address:                             1120 SW Fifth Ave., Room 987
                        Phone Number:                   503-823-6031

The Federal Newborns’ and Mothers’ Health Protection Act of 1996

The Federal Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA) relates to the amount of time a mother and newborn child can spend in the hospital in connection with the birth of a child. Under NMHPA, if a group health plan provides health coverage for hospital stays in connection with the birth of a child, this coverage must be provided for a minimum period of time. For example, NMHPA provides that coverage for a hospital stay following a normal vaginal delivery may generally not be limited to less than 48 hours for both the mother and newborn child. Health coverage for a hospital stay in connection with childbirth following a cesarean section may generally not be limited to less than 96 hours for both the mother and newborn child. The City of Portland’s health plans are in compliance with NMHPA.

Federal Women’s Health and Cancer Rights Act of 1998

The City of Portland’s plans, as required by the Federal Women’s Health and Cancer Rights Act of 1998 (Women’s Health Act) provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema.) Call your Plan Administrator at 503-243-3974 for more information.

Women’s Health Act Frequently Asked Questions

1. I’ve been diagnosed with breast cancer and plan to have a mastectomy. How will the Women’s Health Act affect my benefits? Under the Women’s Health Act, group health plans offering mastectomy coverage must also provide coverage for reconstructive surgery in a manner determined in consultation with the attending physician and patient. Coverage includes 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 the mastectomy, including lymphedemas.
2. Under the Women’s Health Act, may group health plans impose deductibles or coinsurance requirements for reconstructive surgery in connection with a mastectomy? Yes, but only if the deductibles and coinsurance are consistent with those established for other benefits under the plan or coverage.

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 January 31, 2023.  Contact your State for more information on eligibility –

To see if any other states have added a premium assistance program since January 31, 2023, or for more information on special enrollment rights, contact either:

U.S.  Department of Labor                                 U.S. Department of Health and Human Services

Employee Benefits Security Administration         Centers for Medicare & Medicaid Services

www.dol.gov/agencies/ebsa                            www.cms.hhs.gov

1-866-444-EBSA (3272)                                    1-877-267-2323, Menu Option 4, Ext.  61565

Model General Notice of COBRA Continuation Coverage Rights

** Continuation Coverage Rights Under COBRA**

Introduction

You’re getting this notice because you recently gained coverage under a group health plan (the Plan).  This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it.  When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).  COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end.  For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage.  For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace.  By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.  Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.”  Specific qualifying events are listed later in this notice.  After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”  You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.  Under the Plan, qualified beneficiaries who elect COBRA continuation coverage [choose and enter appropriate information:  must pay or aren’t required to pay] for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

• Your spouse dies;
• Your spouse’s hours of employment are reduced;
• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

• The parent-employee dies;
• The parent-employee’s hours of employment are reduced;
• The parent-employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or

• The child stops being eligible for coverage under the Plan as a “dependent child.”

  
  Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to [enter name of employer sponsoring the Plan], and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee's spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred.  The employer must notify the Plan Administrator of the following qualifying events:

• The end of employment or reduction of hours of employment;
• Death of the employee;
• [add if Plan provides retiree health coverage:  Commencement of a proceeding in bankruptcy with respect to the employer;]; or
• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days [or enter longer period permitted under the terms of the Plan] after the qualifying event occurs.  You must provide this notice to: [Enter name of appropriate party].  [Add description of any additional Plan procedures for this notice, including a description of any required information or documentation.]

How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries.  Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.  Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work.  Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

Disability extension of 18-month period of COBRA continuation coverage

If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months.  The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.  [Add description of any additional Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice.]

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event.  This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child.  This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes.  Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.”  Some of these options may cost less than COBRA continuation coverage.  You can learn more about many of these options at www.healthcare.gov.

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?

In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period[1] to sign up for Medicare Part A or B, beginning on the earlier of

• The month after your employment ends; or
• The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later.  If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage.  However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second.  Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

For more information visit Medicare.gov

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below.  For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa.  (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)  For more information about the Marketplace, visit www.HealthCare.gov.

Keep your Plan informed of address changes

To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members.  You should also keep a copy, for your records, of any notices you send to the Plan Administrator.