2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 28
(10) Ensure that adequate separation between the Health Care Plan and the Health Care Plan Sponsor, as
required in section 164.504(f)(2)(iii) of the privacy standards, is established as follows:
The Health Care Plan Sponsor shall only allow certain named employees or classes of employees or
other persons under control of the Health Care Plan Sponsor who have been designated to carry out
Health Care Plan administration functions, access to PHI. The Health Care Plan Sponsor will maintain
a list of those persons and that list is incorporated into this document by this reference. The access to
and use of PHI by any such individuals shall be restricted to Health Care Plan administration functions
that the Health Care Plan Sponsor performs for the Health Care Plan.
In the event any of the individuals described in (a) above do not comply with the provisions of the Health
Care Plan documents relating to use and disclosure of PHI, the Employer shall impose reasonable
sanctions as necessary, in its discretion. Such sanctions shall be imposed progressively (for example,
an oral warning, a written warning, time off without pay and termination), if appropriate and shall be
imposed so that they are commensurate with the severity of the violation.
“Health Care Plan administration” activities are limited to activities that would meet the definition of payment or
health care operations, but do not include functions to modify, amend or terminate the Health Care Plan or solicit
bids from prospective issuers. “Health Care Plan administration” functions include quality assurance, claims
processing, auditing, monitoring and management of carve-out Health Care Plans, such as vision and dental. It
does not include any employment-related functions or functions in connection with any other benefit or benefit
Health Care Plans.
The Health Care Plan shall disclose PHI to the Health Care Plan Sponsor only upon receipt of a certification by the
Health Care Plan Sponsor that:
The Health Care Plan documents have been amended to incorporate the above provisions; and
The Health Care Plan Sponsor agrees to comply with such provisions.
Disclosure of Enrollment Information to the Health Care Plan Sponsor
Pursuant to section 164.504(f)(1)(iii) of the privacy standards, the Health Care Plan may disclose to the Health Care
Plan Sponsor information on whether an individual is participating in the Health Care Plan or is enrolled in or has
disenrolled from a health insurance issuer or health maintenance organization offered under the Health Care Plan.
Disclosure of PHI to Obtain Stop-loss or Excess Loss Coverage; Disclosures of Genetic Information
Except as otherwise provided below, the Health Care Plan Sponsor hereby authorizes and directs the Health Care
Plan, through the Employer or the Contract Administrator, to disclose PHI to stop-loss carriers, excess loss carriers
or managing general underwriters (“MGUs”) for underwriting and other purposes in order to obtain and maintain
stop-loss or excess loss coverage related to benefit claims under the Health Care Plan. Such disclosures shall be
made in accordance with the privacy standards.
The Health Care Plan will not use or disclose genetic information, including information about genetic testing and
family medical history, for underwriting purposes. The Health Care Plan may use or disclose PHI for underwriting
purposes, assuming the use or disclosure is otherwise permitted under the privacy standards and other applicable
law, but any PHI that is used or disclosed for underwriting purposes will not include genetic information.
“Underwriting purposes” is defined for this purpose under federal law and generally includes any Plan rules relating
to (1) eligibility for benefits under the Health Care Plan (including changes in deductibles or other cost-sharing
requirements in return for activities such as completing a health risk assessment or participating in a wellness
program); (2) the computation of premium or contribution amounts under the Health Care Plan (including discounts
or payments or differences in premiums based on activities such as completing a health risk assessment or
participating in a wellness program); and (3) other activities related to the creation, renewal, or replacement of a
contract for health insurance or health benefits. However, “underwriting purposes” does not include rules relating
to the determination of whether a particular expense or claim is medically appropriate.