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FORDHAM UNIVERSITY

HEALTH REIMBURSEMENT ARRANGEMENT

Summary Plan Description March, 2019

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TABLE O F CO NTE NTS

ABOUT THIS SUMMARY PLAN DESCRIPTION ............................................................................................... 1 ELIGIBILITY AND PARTICIPATION ................................................................................................................. 1

ELIGIBLE EMPLOYEES ........................................................................................................................................ 1 INELIGIBLE PERSONS .......................................................................................................................................... 1 SPOUSE AND DEPENDENT COVERAGE .................................................................................................................. 1 COMMENCEMENT OF PARTICIPATION .................................................................................................................. 2 LEAVES OF ABSENCE .......................................................................................................................................... 2 TERMINATION OF PARTICIPATION ....................................................................................................................... 2 RESCISSION OF COVERAGE ................................................................................................................................. 3 PARTICIPATION UPON REEMPLOYMENT ............................................................................................................... 3

PLAN FUNDING .................................................................................................................................................. 3 BENEFITS ............................................................................................................................................................ 4

REIMBURSEMENTS ............................................................................................................................................. 4 CODE SECTION 213(D) EXPENSES IN GENERAL .................................................................................................... 4 SPECIAL REIMBURSEMENT RULES ....................................................................................................................... 5 MAXIMUM REIMBURSEMENTS ............................................................................................................................ 5 SPECIAL WAIVER RULES .................................................................................................................................... 6 COORDINATION WITH HEALTH CARE FSA ........................................................................................................... 6 REIMBURSEMENT REQUESTS............................................................................................................................... 6 REPAYMENT REQUIREMENTS .............................................................................................................................. 7 CLAIM AND APPEALS.......................................................................................................................................... 7

COBRA COVERAGE ......................................................................................................................................... 10 GENERAL EXPLANATION OF COBRA RIGHTS .................................................................................................... 10 COBRA PARTICIPATION .................................................................................................................................. 10 TERMINATION OF COBRA ................................................................................................................................ 11 COBRA CONTINUATION CHART ....................................................................................................................... 12 USERRA ......................................................................................................................................................... 12

AMENDMENT AND TERMINATION ............................................................................................................... 12 MISCELLANEOUS............................................................................................................................................. 13

OFFICIAL PLAN INFORMATION .......................................................................................................................... 13 PLAN SPONSOR AND PLAN ADMINISTRATOR ...................................................................................................... 13 AGENT FOR SERVICE OF LEGAL PROCESS .......................................................................................................... 14 THIRD-PARTY ADMINISTRATOR / CLAIMS ADMINISTRATOR ............................................................................... 14 NO GUARANTEE OF EMPLOYMENT .................................................................................................................... 14 ANTI-ASSIGNMENT RULES................................................................................................................................ 14 AUTHORIZED REPRESENTATIVE RULES ............................................................................................................. 15 PLAN DOCUMENT ............................................................................................................................................. 15 LIABILITY OF OFFICERS AND EMPLOYEES .......................................................................................................... 15 LEGAL ACTION ................................................................................................................................................ 16 PAYMENTS TO LEGALLY INCOMPETENT PAYEE ................................................................................................. 16 TAX EFFECTS ................................................................................................................................................... 16 INTERPRETATION.............................................................................................................................................. 16

YOUR RIGHTS UNDER ERISA ......................................................................................................................... 17 RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS............................................................................... 17 CONTINUE GROUP HEALTH PLAN COVERAGE .................................................................................................... 17 PRUDENT ACTIONS BY PLAN FIDUCIARIES ......................................................................................................... 17 ENFORCE YOUR RIGHTS ................................................................................................................................... 17 ASSISTANCE WITH YOUR QUESTIONS ............................................................................................................... 18

HIPAA NOTICE OF PRIVACY PRACTICES ..................................................................................................... 18 PURPOSE AND APPLICABILITY OF THIS PRIVACY NOTICE .................................................................................... 18 USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION ........................................................................ 18

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YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION ............................................................... 22 PLAN RESPONSIBILITIES ................................................................................................................................... 23 CHANGES TO THIS NOTICE................................................................................................................................ 24 CHANGES TO THE PLAN'S POLICIES AND PROCEDURES ....................................................................................... 24 COMPLAINTS .................................................................................................................................................... 24 CONTACT INFORMATION................................................................................................................................... 24

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ABOUT THIS SUMMARY PLAN DESCRIPTION

This Summary Plan Description (“SPD”) summarizes the terms of the Fordham University Health Reimbursement Arrangement (the “Plan”). Fordham University (“Fordham” or “University”) adopted this Plan for the benefit of its eligible employees effective as of January 1, 2018. This SPD describes the terms of the Plan as in effect on January 1, 2019.

The rules and operation of the Plan are described in this SPD as clearly as possible with minimal use of the technical terms appearing in the official legal documents (including applicable insurance contracts). However, the official legal documents remain the final authority and, in the event of a conflict with this SPD, will govern in all cases. The governing documents for this Plan are the Discovery Benefits, Inc. Master and Prototype Health Reimbursement Arrangement basic document and the Adoption Agreement for the Discovery Benefits, Inc. Master and Prototype Health Reimbursement Arrangement. You may request a copy of the official legal documents from the Plan Administrator. A copying charge may apply. See contact information for the Plan Administrator under the Miscellaneous section of this SPD.

ELIGIBILITY AND PARTICIPATION

ELIGIBLE EMPLOYEES

You are eligible to participate in this Plan if you are enrolled in the Enhanced Standard Option under the Medical Plan component of the Fordham University Health and Welfare Plan (“Health and Welfare Plan”). See the SPD for the Health and Welfare Plan to see whether you are eligible for medical coverage under that plan.

INELIGIBLE PERSONS

Employees not described under Eligible Employees above are not eligible to participate in this Plan. Note that leased employees, part-time employees scheduled to work less than 25 hours per week, students, members of the Jesuit order, employees hired on a temporary or seasonal basis, employees covered by a collective bargaining agreement with Local 810, non-resident aliens who do not receive any U.S. income, and employees not covered by the Enhanced Standard Option of the Medical Plan are not eligible for participation in this Plan.

SPOUSE AND DEPENDENT COVERAGE

As a Plan participant you can receive reimbursements of eligible expenses incurred by your eligible spouse and eligible children who are also enrolled in the Enhanced Standard Option. In addition, you can also receive reimbursement for eligible expenses of any parent, adult child or other legally domiciled adult (LDA) who is a federal tax dependent of the employee and is enrolled in the Enhanced Standard Option. You can receive reimbursement for eligible claims for a child who is covered by a qualified medical child support order (QMCSO) under ERISA Section 609 provided you enroll the child in the Enhanced Standard Option under the Medical Plan. A child of a participant (e.g., biological, adopted or placed for adoption, step and eligible foster child and a child under the participant’s or his/her spouse’s of LDA’s guardianship) will be a dependent for purposes of this Plan until the last day of the month in which the child has his or her 26th birthday.

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Your eligible spouse includes your legal spouse to whom you are legally married under the laws of any applicable state or foreign jurisdiction (including same-and opposite-sex spouses) to the extent he or she is recognized as “spouse” under the U.S. federal tax laws. Common law spouses are also eligible, where applicable based on state or foreign law and recognized under U.S. federal tax law.

A medical child support order is a judgment, decree or order (including approval of a property settlement) made under state law that provides for child support or health coverage for the child of a participant. The child becomes an “alternate recipient” and can receive benefits under the Plan, if the order is determined to be “qualified.” You may obtain, without charge, a copy of the procedures governing the determination of qualified medical child support orders from the Plan Administrator.

COMMENCEMENT OF PARTICIPATION

If you are eligible for participation in the Plan, the effective date of your coverage will be the date that your coverage under the Enhanced Standard Option begins.

LEAVES OF ABSENCE

When you apply for an authorized leave of absence (including a leave pursuant to the Family and Medical Leave Act of 1993) you will be advised of the specific requirements regarding the continuation of your participation in Plan coverage. You will also be advised of the requirements to resume your participation should your participation terminate while you are on leave.

If you go on a qualifying leave under the Family and Medical Leave Act of 1993 (“FMLA”), so long as your coverage under the Enhanced Standard Option continues, you will continue participating in this Plan during your FMLA leave. If you are on leave under the Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”), your coverage under the Medical Plan and this Plan will continue on the same terms as before the leave for the first 31 days of your leave. For the remainder of the leave, your rights will be governed by USERRA (e.g., you may be entitled to continuation of coverage for up to 24 months, subject to your timely payments of the full premium). Contact the Plan Administrator for more information about your rights under FMLA or USERRA.

TERMINATION OF PARTICIPATION

Your Plan coverage will terminate at the time when you are no longer enrolled in the Enhanced Standard Option under the Medical Plan, which usually occurs when you terminate employment or transfer to a position of employment in which you are no longer eligible for benefits under the Medical Plan or if and when Fordham eliminates the Enhanced Standard Option.

In addition, your dependent children and spouse will cease to have Plan coverage when they cease to be enrolled in Medical Plan under the Enhanced Standard Option.

Your and/or your spouse’s and dependents’ participation will also terminate when Fordham terminates this Plan or amends it to exclude from participation the group of employees of which you are a member or, with respect to spouses and dependents, amends the Plan to exclude

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spouses and/or dependents from eligibility for reimbursements under the Plan. See the section Amendment and Termination in this SPD.

RESCISSION OF COVERAGE

The Plan will not rescind (as defined below) coverage under the Plan for a participant or qualifying dependent, unless the participant or dependent perpetrates fraud on the Plan or makes an intentional misrepresentation of a material fact with respect to the Plan. If coverage may be rescinded under the foregoing provisions, the participant or dependent will be provided with at least 30 days’ advance written notice of such rescission. A rescission is subject to the claims procedures described under Claims and Appeals later in this SPD.

A “rescission” of Plan coverage is a cancellation or discontinuance of such coverage that has retroactive effect. A cancellation or discontinuance of coverage is not a rescission (and not subject to the rescission of coverage rules) if:

• The participant or dependent voluntarily requests such cancellation or discontinuance with a retroactive effective date;

• The participant fails to make timely contributions to the cost of coverage under the Plan (or the Enhanced Standard Option);

• The cancellation or discontinuance of coverage has only prospective effect;

• The cancellation or discontinuance of coverage results from a participant’s termination of employment from the University; or

• The cancellation or discontinuance of coverage for a dependent results from such dependent’s failing to satisfy the applicable eligibility requirements to be a dependent.

PARTICIPATION UPON REEMPLOYMENT

If you terminate employment with the University and are later reemployed, you will be a participant upon reemployment when you again become an eligible employee (i.e., enroll in the Enhanced Standard Option) to the extent that the Plan is still in effect at that time.

PLAN FUNDING

Contributions for Plan coverage are made by Fordham. You are not permitted to make contributions to the Plan. Benefits are self-insured and paid out of Fordham’s general assets. The Claims Administrator is not responsible for funding or insuring Plan benefits.

The Plan Administrator or the Claims Administrator will establish bookkeeping accounts for participants in this Plan (each, an “HRA Account”). However, no actual assets will be set aside or deposited in these HRA Accounts and no individual will have any claim to any particular assets of the University. HRA Accounts are established purely for accounting purposes to keep track of the amounts available for reimbursement of eligible expenses and reimbursements made. Each year, the University will determine the amounts to be made available for reimbursement. For example, the University may credit to HRA Accounts for a Plan Year $400 for participants

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with employee-only coverage under the Medical Plan and $800 for participants with family coverage under the Medical Plan. As you submit claims for reimbursement, your HRA Account will record the reimbursed expense as an account debit.

BENEFITS

REIMBURSEMENTS

The Plan allows you to be reimbursed for Qualifying Medical Expenses. Qualifying Medical Expenses that can be reimbursed by the Plan are limited to the following:

• Medical deductibles paid under the Enhanced Standard Option,

• Medical co-insurance paid under the Enhanced Standard Option,

• Medical co-payments paid under the Enhanced Standard Option,

• Pharmacy deductibles, co-insurance and/or co-payments paid under the Enhanced Standard Option, and/or

• Dental and vision expenses under the University’s Dental and Vision Plans.

However, in all cases, you cannot be reimbursed for individual insurance premiums and employer group health plan premiums.

CODE SECTION 213(D) EXPENSES IN GENERAL

Remember that all expenses listed above must be eligible medical expenses within the meaning of Code Section 213(d). Thus, the IRS requires the expense to be:

• For the diagnosis, cure, mitigation, treatment or prevention of disease and for treatments affecting any part or function of the body, and

• Primarily to alleviate or prevent a physical or mental defect or illness.

Expenses NOT generally eligible for reimbursement are those:

• Solely for cosmetic reasons, or

• Merely beneficial to one’s general health (for example, health spas, vacations)

Further, you cannot receive any reimbursements for over the counter medicines or drugs, unless you have a written prescription for such medicine or drug from your physician.

If you have any questions as to whether an expense satisfies the Code Section 213(d) requirements, please review the rules set forth on the Claims Administrator's website at www.discoverybenefits.com, or contact Participant Services at 1-866-451-3399 or via email at customerservice@discoverybenefits.com.

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SPECIAL REIMBURSEMENT RULES

Reimbursements of Qualifying Medical Expenses under the Plan are subject to the following rules:

• Any expense submitted for reimbursement under the Plan cannot also be reimbursed or paid by any other health plan.

• You must file any claims for eligible expenses by the end of the 90-day period following the end of the Plan Year during which the eligible expense was incurred. Claims filed after the end of that period will not be paid. Expenses incurred prior to the effective date of the Plan or before you began Plan participation are not eligible for reimbursement.

• Any money you don’t use in a particular Plan Year will carry over to the following Plan Year, but not beyond the Plan Year ending on December 31, 2020. Any balances remaining in HRA Accounts as of December 31, 2020 (as determined at the end of the 90-day claim submission period) will be forfeited.

• If you leave the University or otherwise terminate Plan participation, you have until the end of the year following the year in which the expense is incurred, but in no event later than March 31, 2021, to submit those expenses for reimbursement. You will be able to file claims for eligible expenses incurred after your termination, only if you are a Pre-Medicare Retiree and eligible to participate and enroll in the Retiree Medical Plan. See below for additional information.

• If you die while employed by the University, your eligible spouse and eligible dependents can continue to use the HRA Account for their eligible expenses incurred both before and after your death until the HRA Account is exhausted, subject to any waiver requirements. See below for additional information.

You “incur” an expense when services or supplies are provided and not when you are billed for or pay the expense charged.

Participants may be provided with a debit card by the Claims Administrator to pay for Qualifying Medical Expenses. Any debit card will be subject to the debit card’s terms of use and any other requirements established by the Claims Administrator for this purpose. If a debit card is used to pay for an expense that is not a Qualifying Medical Expense, the Claims Administrator will apply correction procedures as set forth in guidance promulgated pursuant to Section 125 of the Internal Revenue Code.

MAXIMUM REIMBURSEMENTS

The amount that Fordham will credit to your HRA Account is set forth in the Adoption Agreement. Currently, this amount is $400 for a participant who is enrolled in employee-only medical coverage and $800 for a participant who is enrolled in any tier of medical coverage other than employee-only (e.g., family coverage) under the Enhanced Standard Option. Unused amounts from the prior Plan Year may be carried forward to subsequent Plan Years only as described under Special Reimbursement Rules above. You may not be reimbursed for an amount

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of eligible expenses that is greater than your HRA Account balance at the time the reimbursement is to be made. Any excess amount will be carried over to the next reimbursement cycle.

After your Plan eligibility terminates, no additional amounts will be credited to your HRA Account. However, you may be able to spend down the remaining balance in your HRA Account for eligible claims incurred after termination as described under Special Reimbursement Rules above. If a spend down feature does not apply to you, then you will not be able to use your HRA Account for claims incurred after your eligibility terminates.

SPECIAL WAIVER RULES

You may be eligible for special waiver rules, as follows –

• You will be allowed to voluntarily forfeit any future coverage from the Plan upon your termination (even if you are eligible to continue using your HRA Account). Completing a waiver in this situation means that you forfeit the existing balance of the HRA Account and you cannot be reimbursed for any claim incurred after the effective date of the waiver.

• If your balances carry forward to the next Plan Year, you will be allowed to voluntarily forfeit any future coverage from the HRA Account for the following Plan Year. Completing a waiver in this situation means that you forfeit the existing balance of the HRA Account for the following Plan Year and you cannot be reimbursed for any claim incurred during the Plan Year to which the waiver applies.

All waivers are subject to the terms and conditions as set forth on the waiver form. All waivers are irrevocable once made. Contact the Plan Administrator or the Claims Administrator for any waiver questions.

If a waiver is available, you may wish to make such a waiver if you intend to enroll in an individual policy through the Insurance Marketplace and use premium tax credits to pay for all or a portion of such policy’s premiums. You should contact your personal tax advisor for any questions related to claiming premium tax credits.

COORDINATION WITH HEALTH CARE FSA

When you submit your claim for reimbursement, the funds in your Health Care FSA will be applied first when you use your FSA debit card. However, you can elect to use the funds in your HRA Account before using funds in the FSA Account. Simply submit your expenses to the Claims Administrator of this Plan instead of using your FSA debit card to pay for the expense. Note also that if you incur expenses that may be eligible for reimbursement from the Medical Assistance Fund (“MAF”), your Health FSA and this Plan will be used first to reimburse you for any unpaid claims. Any balance of your eligible expenses that has not been reimbursed by the Health FSA and this Plan will be reimbursed by the MAF in whole or in part (i.e., when the MAF funds are less than the total amount of eligible claims submitted by all participants and are, therefore, allocated to participants’ claims pro rata).

REIMBURSEMENT REQUESTS

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During the course of the Plan Year, you may submit requests for reimbursement of expenses you have incurred. However, you must make your requests for reimbursements no later than 90 days after the end of the Plan Year in which the expense was incurred or, if you terminate employment, one year after the Plan Year in which the expense was incurred, but in no event later than March 31, 2021. The Claims Administrator will provide you with acceptable forms for submitting these requests for reimbursement. In addition, you must submit to the Claims Administrator proof of the expenses you have incurred and that they have not been paid by any other health plan coverage. If the request qualifies as a benefit or expense that the Plan has agreed to pay, you will receive a reimbursement payment soon thereafter.

REPAYMENT REQUIREMENTS

Reimbursement under the Plan is conditioned on your agreement to repay the reimbursement in whole or in part under the following circumstances. By accepting reimbursements under the Plan, you agree to repay any improperly paid amounts and indemnify the University for any losses it may incur in connection with reimbursements that were paid to you under the Plan. The Plan Administrator may recoup any excess reimbursement from you directly or by reducing reimbursement for your other eligible expenses under the Plan.

Reimbursement from Another Source

If, after you have been reimbursed under the Plan for an expense, that expense is paid by another source or you, your spouse, or dependent receive (directly or indirectly) reimbursement of that expense form another source, then you must reimburse the University for that expense.

Fraud or Misrepresentation

If you obtained any reimbursement through fraud or intentional misrepresentation of a material fact, you must repay the amount of reimbursement back to the University. The Plan Administrator may also terminate your future participation in the Plan. You will be notified 30 days in advance of the requirement to repay the benefit you procured through fraud or misrepresentation.

Miscalculation

If any reimbursement was paid to you because of the Claims Administrator’s mistake in determining the amount that can be properly reimbursed, you must repay the excess amount back to the University.

CLAIM AND APPEALS

When you have a claim to submit for reimbursement, you must:

(1) Obtain a claim form from the Claims Administrator;

(2) Complete the Employee portion of the form; and

(3) Attach copies of all bills or receipts from the healthcare provider for which you are requesting reimbursement.

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All claims must be filed within the period described under the Special Reimbursement Rules section of this SPD.

A claim is defined as any request for a Plan benefit, made by a participant or by a representative of the participant that complies with the Plan’s reasonable procedure for making benefit claims. The times listed are maximum times only. A period of time begins at the time the claim is filed. Decisions will be made within a reasonable period of time appropriate to the circumstances but no later than the time periods set forth below. “Days” means calendar days.

Notification of whether claim is accepted or denied 30 days

Extension due to matters beyond the control of the Plan (with notice of the extension provided before the end of the initial 30-day period)

15 days

Insufficient information on the claim:

Notification of insufficient information 15 days

Required Response by the claimant 45 days

If you need to provide additional information for the Claims Administrator to make a decision on your claim, the period the Claims Administrator has to decide the claim will be tolled from the date on which the notice is sent to you until the date on which you respond to the request for additional information.

The Claims Administrator will provide written or electronic notification of any claim denial. The notice will contain:

(1) The specific reason or reasons for the denial;

(2) Reference to the specific Plan provisions on which the denial was based;

(3) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary;

(4) A description of the Plan’s review procedures and the time limits applicable to such procedures. This will include a statement of your right to bring a civil action under Section 502 of ERISA following a denial on review;

(5) A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim;

(6) If the denial was based on an internal rule, guideline, protocol, or other similar criterion, the specific rule, guideline, protocol, or criterion will be provided free of

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charge. If this is not practical, a statement will be included that such a rule, guideline, protocol, or criterion was relied upon in making the denial and a copy will be provided free of charge to the claimant upon request; and

(7) If a denied claim is based on medical necessity, experimental treatment, or similar limit, a statement explaining the scientific or clinical judgment (if any) used in applying the terms of the Plan to your medical circumstances or a statement that such explanation will be provided free of charge to you.

When you receive a denial, you will have 180 days following receipt of the notification in which to appeal the decision. You may submit written comments, documents, records, and other information relating to the claim. If you request, you will be provided, free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim.

A document, record, or other information will be considered relevant to a claim if it:

(1) was relied upon in making the claim determination;

(2) was submitted, considered, or generated in the course of making the claim determination, without regard to whether it was relied upon in making the claim determination;

(3) demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify that claim determinations are made in accordance with Plan documents and Plan provisions have been applied consistently with respect to all claimants; or

(4) Constituted a statement of policy or guidance with respect to the Plan concerning the denied claim.

Once an appeal is filed, the Claims Administrator will notify you within 60 days thereafter of whether the appeal is approved or denied.

The review will take into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial claim determination. The review will not afford deference to the initial denial and will be conducted by a fiduciary of the Plan who is neither the individual who made the adverse determination nor a subordinate of that individual.

If your claim is wholly or partially denied on review, the notice of the decision on review will inform you of the specific reasons for the denial; the specific provisions of the Plan upon which the denial is based; a statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relied on, submitted, considered, generated, or demonstrating compliance with the procedures in connection with the determination; the specific internal rule, guideline, protocol, or similar factor (if any) on which the adverse determination was based or a statement that a copy thereof is available to you free of charge upon request; if a denied claim is based on medical necessity, experimental treatment, or similar limit, a statement explaining the scientific or clinical judgment (if any) used in applying the terms of the Plan to your medical circumstances or a statement that

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such explanation will be provided free of charge to you; a statement of your right to bring a civil action under Section 502 of ERISA; and the following statement: “You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office.”

The decision of the Claims Administrator on review of the claim denial is final and binding on all parties. Benefits under the Plan will be paid only if the Claims Administrator decides that you (or any person on your behalf) are entitled to benefits under the Plan.

If you fail to follow the claims and appeal procedures described above, you will be precluded from brining an action in any court.

COBRA COVERAGE

GENERAL EXPLANATION OF COBRA RIGHTS

You and your dependents may have the option to extend your Plan coverage at group rates in certain instances when coverage would otherwise end (or the cost of coverage would increase). This is called COBRA coverage. COBRA stands for the Consolidated Omnibus Budget Reconciliation Act of 1985. This section gives you a general description of your rights under COBRA.

At the same time, you may have other health coverage options as well. Instead of enrolling in COBRA continuation coverage, you may have other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, 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, and provide more coverage. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace. You can learn more about many of these options at www.healthcare.gov or by calling 1-800-318-2596.

COBRA PARTICIPATION

If one of the circumstances listed in the COBRA continuation chart below causes you or a dependent to lose health coverage, you may continue group health plan coverage (each is called a “qualifying event”) for yourself and your dependents if you pay the entire cost of coverage, with an additional 2 percent to cover administrative expenses.

Continued coverage is available to you, your spouse and/or dependents who were enrolled in the Plan on the date of a qualifying event (each of them called a “qualified beneficiary”) for a maximum of 18, 29, or 36 months, depending on the circumstances outlined in the chart below.

You, your spouse, or your dependent children MUST contact Fordham within 60 days of your divorce or legal separation from your spouse or your child’s ceasing to qualify as a dependent. If you fail to notify Fordham of any of these events within the prescribed period, your spouse or dependent children may lose eligibility for COBRA continuation coverage.

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You or your spouse or dependents MUST also notify the Plan Administrator if you or your covered spouse or dependent is determined by the Social Security Administration to have been disabled during the first 60 days of your COBRA coverage and continue to be disabled during the COBRA coverage period. Disability entitles you and all qualified beneficiaries for an extension of COBRA coverage beyond 18 months up to a total of 29 months from the date of your termination of employment or reduction in hours that result in a loss of coverage. To be eligible for the extension, you must notify the Plan Administrator of the disability determination both within the initial 18-month period and within 60 days of the date the determination is made. During the disability extension period, you or your dependents must pay 150% of the full group rate for continued coverage. If the disability ceases, notice should be provided within 30 days of the final determination that the disability has ended.

If COBRA is elected, the coverage previously in effect will generally be continued. From time to time, some changes in coverage are possible. For example, coverage and cost will be modified as the University makes regular changes to the programs, and you will be given the opportunity to make a new election during annual enrollment or when you have a change in family status (if applicable). Any newly eligible dependents you may have may be covered under the same rules that apply to active employees.

You or your eligible dependents have 60 days after you receive a COBRA notice to elect continued participation under COBRA. You and each qualified beneficiary (including your spouse and dependent children that were covered by the Plan on the date the qualifying event occurred) may make a separate COBRA election. An election by you or your spouse to continue coverage will apply to all the qualified beneficiaries losing coverage in the same qualifying event, unless the election specifies otherwise. Once you make your election, you will have up to 45 days to pay any make-up premiums you missed and the monthly premium for the current month. All subsequent premiums must be paid within 30 days after the due date for premium payments (usually the first day of each month). COBRA coverage will be effective the day after the qualifying event.

TERMINATION OF COBRA

COBRA coverage will terminate before the end of the maximum applicable time period if:

• You or your dependent become covered under another group healthcare plan after electing COBRA.

• You or certain of your dependents become entitled to Medicare after electing COBRA continuation coverage.

• The first required premium is not paid within 45 days or any subsequent premium is not paid within 30 days of the due date.

• If coverage is extended beyond 18 months because of disability, the date a final determination is made that the individual is no longer disabled.

• All health plans for active employees are terminated by Fordham.

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COBRA CONTINUATION CHART

CIRCUMSTANCES (“qualifying events”)

MAXIMUM CONTINUATION PERIOD (from the qualifying event)

EMPLOYEE SPOUSE CHILD Employee loses coverage because of reduced work hours

18 months 18 months 18 months

Employee terminates for any reason (except gross misconduct)

18 months 18 months 18 months

A qualified beneficiary is disabled (as defined by Title II or XVI of the Social Security Act) during the first 60 days of COBRA coverage

29 months 29 months 29 months

Employee dies N/A 36 months 36 months Employee and spouse legally separate or divorce

N/A 36 months N/A

Employee becomes entitled to Medicare within 18 months before termination of employment

36 months (from Medicare

entitlement)

36 months (from Medicare

entitlement)

36 months (from Medicare

entitlement) Child no longer qualifies as dependent

N/A N/A 36 months

USERRA

The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) established requirements that employers must meet for certain employees who are involved in the uniformed services. If your coverage under the Plan terminates due to your service in the uniformed services, you may elect special continuation coverage under USERRA for yourself and your covered dependents. Please contact Fordham for additional information if you think these special rules apply to you.

AMENDMENT AND TERMINATION

Fordham reserves the right to discontinue or terminate the Plan, or to reduce, amend or modify coverage in whole or in part and in any respect. The Claims Administrator also has the right to amend and revise certain provisions in its standard prototype documents that Fordham has adopted for its use in connection with the Plan. This may be done at any time and without advance notice. Benefits for claims occurring after the effective date of a modification or termination are payable in accordance with the revised provisions of the Plan. The Plan will automatically terminate on December 31, 2020 but expenses incurred before the termination of the Plan will be reimbursed so long as they are timely filed with the Claims Administrator.

This right applies without limitation even after an individual’s circumstances have changed by retirement, termination or otherwise. Benefits under this Plan do not become vested at any time.

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The Plan Administrator may in its sole discretion adjust the benefits payable to any individual who is considered to be highly compensated in order to comply with the nondiscrimination requirements.

MISCELLANEOUS

OFFICIAL PLAN INFORMATION

The Plan is an employee welfare benefit plan under the Employee Retirement Income Security Act of 1974 (ERISA), as amended.

The official name of the Plan is the Fordham University Health Reimbursement Arrangement.

The financial and other records for the Plan are kept on a plan year basis. The Plan Year ends on each December 31.

The Plan identification number is 577.

PLAN SPONSOR AND PLAN ADMINISTRATOR

The Plan Sponsor is Fordham University and its address and telephone number are:

441 East Fordham Road, FMH506 Bronx, NY 10458 Telephone: 718-817-1000

The Plan Sponsor’s Employer Identification Number is 13-1740451.

The Plan Administrator is Fordham or such person or person as Fordham appoints to administer the Plan. Contact information for the plan administrator is:

441 East Fordham Road, FMH506 Bronx, NY 10458 Telephone: 718-817-1000

The Plan Administrator will have complete control of the administration of the Plan and will serve without additional compensation, except for reimbursement of out-of-pocket expenses.

The Plan Administrator has authority, in its discretion to do the following:

• To construe and interpret the terms of the Plan (including any ambiguities, omissions and inconsistencies in the terms of the Plan); decide all questions of eligibility for participation and benefits under the Plan; determine the amount, manner and time of payment or provision of any benefits under the Plan and make any factual determinations under the Plan;

• To prescribe procedures to be followed by Participants in filing applications for benefits under the Plan;

• To provide for the preparation and distribution of Plan information;

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• To receive from the University and from Participants, directly or indirectly, all information necessary for the proper administration of the Plan;

• To designate, appoint or employ individuals to assist in the administration of the Plan and any other agents; and

• To discharge all other duties of the Plan Administrator.

The Plan Administrator may allocate or delegate any responsibility regarding the Plan among one or more Plan Administrators and may designate other persons, which persons may be either named fiduciaries or persons other than fiduciaries, to carry out such responsibilities.

AGENT FOR SERVICE OF LEGAL PROCESS

Legal process may be served on the University at the address of the Plan Sponsor listed above.

THIRD-PARTY ADMINISTRATOR / CLAIMS ADMINISTRATOR

Discovery Benefits, Inc. provides certain third-party administration services related to the Plan. In particular, Discovery Benefits (“Claims Administrator”) processes all claims for reimbursement of eligible medical expenses under the Plan and reviewing all appeals of claim denials. Contact information is as follows –

Discovery Benefits, Inc. 4321 20th Avenue S Fargo, ND 58103 Phone: (718) 817-4930 www.discoverybenefits.com

NO GUARANTEE OF EMPLOYMENT

Nothing in the Plan gives you or any other individual rights of continued employment with the University or any affiliated employer or in any way alter your or any individual’s employment status with the University or any affiliated employer or limit the right of the University or an affiliated employer to terminate your employment or employment of any employee. Furthermore, the Plan does not constitute a contract of employment.

ANTI-ASSIGNMENT RULES

Your rights and benefits under the Plan cannot be assigned, sold or transferred to any person, including your healthcare provider. For this purpose, your Plan rights and benefits, include, without limitation, the right to file an administrative appeal, the right to sue following a denied administrative appeal, and any other Plan rights and benefits, whether actual or potential. Any purported assignment of rights and/or benefits under the Plan will be void and will not apply to the Plan. Further, a payment or reimbursement of eligible expenses by the Claims Administrator to a health care provider (whether pursuant to an authorization or otherwise) will not waive the application of this provision.

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In addition, during a visit to your healthcare provider, your provider may ask you to authorize him / her to receive payments directly for your covered healthcare services. Such authorizations to receive direct payments are not assignments of benefits or rights under the Plan. Further, such authorizations are void and will not apply to the Plan.

Any payments made directly to you of claims for benefits will fulfill the Plan’s obligation to make a payment. The Plan is not responsible for paying healthcare provider invoices that are balance-billed to you.

AUTHORIZED REPRESENTATIVE RULES

You may appoint an authorized representative to act on your behalf for purposes of the Plan. If you need to appoint an authorized representative for any purpose, your appointment of an authorized representative must:

• Be in writing and dated;

• Clearly indicate the authorized representative, the scope of the appointment and any limitations on the authorized representative;

• Be signed by you and notarized by a notary public;

• Satisfy any other legal requirement applicable to appointments under state or federal law; and

• Be approved by the Claims Administrator (or its delegate) in writing.

The Plan will also recognize a court order appointing a person as your authorized representative. The Claims Administrator or Plan Administrator may also provide different rules and procedures for an appointment of an authorized representative in emergency situations or for attorneys.

Appointing an individual or entity as your authorized representative is not an assignment of rights or benefits under the Plan and any such appointment (whether pursuant to the rules of a Claims Administrator or the Plan Administrator) does not waive the Plan’s anti-assignment provisions.

PLAN DOCUMENT

This SPD is not an official plan document. The legal document governing this Plan is the official documents for the Plan (including the Discovery Benefits, Inc. Master Prototype Plan and associated Adoption Agreement). In the case of any conflict between the terms of this SPD (as it may be from time to time modified) and the official Plan document, the provisions of the official Plan documents will control.

LIABILITY OF OFFICERS AND EMPLOYEES

No officer or employee of the University, except for any officer or employee of the University who is acting in a fiduciary capacity, will incur any personal liability of any nature for acts done or omitted to be done in good faith in connection with his duties relative to the Plan.

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LEGAL ACTION

Before pursuing legal action, a person claiming Plan benefits must first exhaust all claim, review, and appeal procedures provided by the Plan.

• Unless otherwise required by law, the Plan Administrator is the only necessary party to any action or proceeding that involves the Plan or its administration.

• No employee or other person or entity is entitled to notice of any legal action, unless a court with appropriate jurisdiction orders otherwise.

• All legal actions with respect to Plan benefits must be brought by the later of (i) one year after the date a covered expense was incurred or (ii) one year after the Claims Administrator’s final denial of the claim on review.

PAYMENTS TO LEGALLY INCOMPETENT PAYEE

If a distribution is to be made to an individual who is legally incompetent, the Plan Administrator may pay the benefit to the individual’s legal guardian, conservator or other person legally responsible for the care of his estate. Every person receiving or claiming benefits under the Plan is presumed to be mentally and physically competent and of age until the Plan Administrator receives a written notice, in acceptable form, that a person is mentally or physically incompetent or a minor, and that a guardian, conservator or other person legally vested with the care of his estate has been appointed.

TAX EFFECTS

The amounts you receive as reimbursement under the Plan are not subject to federal income taxes, Social Security and Medicare taxes, and, in most cases, state and local income taxes. The value of coverage under the Plan provided to your family members who are not your tax dependents or not children under age 26 will be taxed to you as additional taxable compensation. Note, however, that neither the University nor the Plan Administrator guarantee any specific tax consequences of participation in the Plan or receipt of benefits under the Plan. You are solely responsible for payment of the tax liability (if any) in connection with this Plan and by accepting benefits you agree to indemnify the University from any liability for tax withholding that may apply to the benefits payable to you under the Plan.

INTERPRETATION

In the event that any provision of this Plan are held to be illegal or invalid for any reason by a court of competent jurisdiction, such illegality or invalidity will not affect the remaining provisions of the Plan, and the Plan must be construed and enforced as if such illegal or invalid provision had never been contained in the Plan. The headings of this SPD are for reference only, and must not determine the interpretation or construction of this Plan. The Plan must be construed and administered in accordance with the Employee Retirement Income Security Act (ERISA). To the extent ERISA does not pre-empt state law, the laws of the State of New York will govern the Plan without regard to any conflict of law provisions.

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YOUR RIGHTS UNDER ERISA

The following statement is required by federal law. As a participant in the group health plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to the following rights:

RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS

You may examine, without charge, at the employer’s office and at other specified locations, such as worksites, all documents governing the plans, including insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. You may obtain, upon written request to the employer, copies of documents governing the operation of the plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and updated summary plan descriptions. The employer may make a reasonable charge for the copies. You will receive a summary of the plan’s annual financial reports. The employer is required by law to furnish each participant with a copy of this summary annual report.

CONTINUE GROUP HEALTH PLAN COVERAGE

You may continue coverage for yourself, your spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this SPD and the documents governing the plan on the rules governing your COBRA continuation coverage rights.

PRUDENT ACTIONS BY PLAN FIDUCIARIES

In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plans. The people who operate your plans, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.

ENFORCE YOUR RIGHTS

If your claim for a plan benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the plan documents and/or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the employer to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the employer. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in a federal court. If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against for asserting your rights, you may

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seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees if, for example, it finds your claim is frivolous.

ASSISTANCE WITH YOUR QUESTIONS

If you have any questions about a plan, you should contact Fordham. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from Fordham, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY PURPOSE AND APPLICABILITY OF THIS PRIVACY NOTICE

The Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”) and the rules implementing HIPAA set forth in 45 C.F.R. Parts 160 and 164 (the “Privacy Rules”) require a health plan to notify participants and beneficiaries about the policies and practices the plan has adopted to protect the confidentiality of their Protected Health Information (as defined below). This Notice of Privacy Practices (“Notice”) applies to the medical benefits provided under the Fordham University Health Reimbursement Arrangement (the “Plan”), which is sponsored by Fordham (the “Plan Sponsor”).

This Notice describes how your Protected Health Information may be used or disclosed by the Plan to carry out treatment, payment or healthcare operations and for other purposes that are permitted or required by applicable law. It also describes your rights to access and control your Protected Health Information held by the Plan.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

“Protected Health Information” is generally your individually identifiable health information, including demographic and genetic information that relates to (i) your past, present or future physical or mental health or condition, (ii) your healthcare treatments, or (iii) payments for your healthcare treatment.

The Privacy Rules protect your Protected Health Information from inappropriate use or disclosure. All individuals who have access to, or use or disclose, your Protected Health Information are required to comply with requirements that protect the confidentiality of your Protected Health Information. Your Protected Health Information may be used or disclosed

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without your authorization only when there is an appropriate reason to do so, such as for payment or administration of necessary healthcare services. If practicable, the Plan will limit the uses and disclosures of your Protected Health Information to the minimum necessary to serve the purpose for which the information was requested.

Payment, Treatment and Health Care Operations: The main reasons for which your Protected Health Information held by the Plan may be used or disclosed are to evaluate and process your requests for coverage and claims for benefits or in connection with other health-related benefits or services that may be of interest to you. These and other types of permitted or required uses and disclosures are described below, together with some examples of such uses and disclosures. The description and examples below are not meant to be exhaustive, but rather intended to illustrate some common instances in which Protected Information may be used or disclosed.

For Payment: Your Protected Health Information may be used or disclosed for purposes of payment for your benefits under the Plan. For example, your Protected Health Information may be reviewed to reimburse providers for services rendered or may be disclosed to insurance carriers or third party administrators to coordinate benefits with respect to a particular claim. The Plan may disclose your Protected Health Information to an administrator of the Plan for various payment related functions, such as eligibility determination, audit and review or assisting with any inquiries or disputes. The Plan may disclose your Protected Health Information to a health care provider when the provider requests information regarding your eligibility for benefits under the Plan.

For Health Care Operations: Your Protected Health Information may be used or disclosed to conduct various business, management and administrative functions of the Plan. These functions include, but are not limited to, evaluating a request for Plan products or services, administering those products or services, and processing transactions upon your request. However, the Plan is prohibited from using or disclosing Protected Health Information that is genetic information for underwriting purposes.

For Treatment: The Plan may disclose your Protected Health Information to a health care provider who is providing treatment. If you are incapacitated, there is an emergency, or you otherwise are not present or do not have the opportunity to agree to or object to this use or disclosure, we will do what in our judgment is in your best interest regarding such disclosure and will disclose only information that is directly relevant to the person's involvement with your health care. However, if you are present for, or otherwise available prior to this use or disclosure, and you have the capacity to make health decisions, the Plan will use or disclose your Protected Health Information if you agree, if you did not object to the use or disclosure after being given an opportunity to object or the Plan can reasonably infer from the circumstances that you do not object.

To Business Associates: The Plan may disclose your Protected Health Information to business associates who are assisting the Plan if they need to receive Protected Health Information to provide you health-related benefits and services or information on treatment alternatives. Business associates must abide by the HIPAA privacy rules relating to the protection of your Protected Health Information. Moreover, business associates may receive, create, maintain, use, or disclose your Protected Health Information only after the Plan and these business associates agree in writing that the business associates will appropriately safeguard your Protected Health

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Information. Examples of business associates are billing companies, data processing companies, or companies that provide general administrative services.

To the Plan Sponsor: The Plan, or a health insurance issuer, HMO or third party administrator acting on behalf of the Plan, may disclose Protected Health Information to the Plan Sponsor for Plan administration purposes. Only certain designated employees of the Plan Sponsor will have access to, and will be able to use, your Protected Health Information to carry out their duties to administer the Plan, but cannot use or disclose your Protected Health Information for employment-related purposes or to administer other benefit plans. The Plan may disclose information to the Plan Sponsor that summarizes the claims experience of Plan participants as a group, but without identifying specific individuals, to obtain premium bids for new benefit insurance or to amend or terminate the Plan. The Plan may also disclose limited Protected Health Information to the Plan Sponsor in connection with the enrollment or disenrollment of individuals in the Plan.

When Required by Law or for Public Health Activities: Your Protected Health Information may be disclosed when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases, or providing Protected Health Information to a governmental agency or regulator with healthcare oversight responsibilities. Protected Health Information may also be released to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death. The Plan also may disclose Protected Health Information to funeral directors as necessary to carry out their duties.

To Avert a Serious Threat to Health or Safety: Protected Health Information may be disclosed to avert a serious threat to the health or safety of the public or individual. Protected Health Information may also be disclosed to federal, state or local agencies engaged in disaster relief as well as to private disaster relief or disaster assistance agencies to allow such entities to carry out their responsibilities in specific disaster situations.

For Health-Related Benefits or Services: Your Protected Health Information will not be disclosed to any other company for their marketing use. However, your Protected Health Information may be used to provide you with information about treatment alternatives or other health-related benefits available to you under your current coverage or policy and, in limited situations, about health-related products or services that may be of interest to you, such as case management, disease management, wellness programs, or employee assistance programs.

For Law Enforcement or Specific Government Functions: Protected Health Information may be disclosed in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. Protected Health Information about you may be disclosed to federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

When Requested as Part of a Regulatory or Legal Proceeding: If you or your estate are involved in a lawsuit or a dispute, your Protected Health Information may be disclosed in response to a court or administrative order. Your Protected Health Information may be disclosed in response to a subpoena, discovery request, or other lawful process by other parties involved in the dispute, but only if good faith efforts have been made to notify you about the request or to

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obtain an order protecting the Protected Health Information requested. Your Protected Health Information may be disclosed to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination.

To Other Covered Entities: The Plan may use or disclose your Protected Health Information to assist health care providers in connection with their treatment or payment activities, or to assist other covered entities in connection with certain payment activities or health care operations. For example, the Plan may disclose Protected Health Information to another covered entity to conduct health care operations in the areas of quality assurance and improvement activities, patient safety activities, or accreditation, certification, licensing, or credentialing. This also means that the Plan may disclose or share your Protected Health Information with other health care programs or insurance carriers (such as Medicare etc.) in order to coordinate benefits, if you or your family members have other health insurance or coverage.

To Comply with Workers' Compensation Laws: The Plan may disclose your Protected Health Information to comply with workers' compensation laws and other similar programs that provide benefits for work-related injuries or illnesses.

To Military Authorities: Under certain conditions, if you are, or were, armed forces personnel, the Plan may disclose your Protected Health Information for activities deemed necessary by appropriate military command authorities. If you are a member of foreign military service, the Plan may disclose, in certain circumstances, your information to the foreign military authority.

To Others Involved in Your Health Care: The Plan may disclose your Protected Health Information to a friend or family member who is involved in your health care, unless you object or request a restriction (in accordance with the process described below under “Right to Request Restrictions”). If you are not present or able to agree to these disclosures, then, using professional judgment, the Plan reserves the right to determine whether the disclosure is in your best interest. The Plan may also disclose a decedent’s Protected Health Information to family members and others who were involved in the care or payment for care of the decedent prior to death, unless doing so is inconsistent with any prior expressed preference of the individual that is known to the Plan.

To You or Your Personal Representative: The Plan is required to disclose to you or your personal representative most of your Protected Health Information when you request access to this information. The Plan will disclose your Protected Health Information to an individual who has been designated by you as your personal representative and who has qualified for such designation in accordance with relevant law. Prior to such a disclosure, however, the Plan must be given written documentation that supports and establishes the basis for the personal representation. The Plan may elect not to treat the person as your personal representative if the Plan has a reasonable belief that you have been, or may be, subjected to domestic violence, abuse, or neglect by such person or treating such person as your personal representative could endanger you and the Plan determines, in the exercise of professional judgment, that it is not in your best interest to treat the person as your personal representative.

In Case of Abuse, Neglect or Domestic Violence: As required by law, the Plan may disclose your Protected Health Information to a government authority that is authorized by law to receive reports of abuse, neglect, or domestic violence. Additionally, as required by law, if the Plan

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believes you have been a victim of abuse, neglect, or domestic violence, they may disclose your Protected Health Information to a governmental entity authorized to receive such information.

To the Secretary of the U.S. Department of Health and Human Services: The Plan is required to disclose your Protected Health Information to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining the Plan’s compliance with the Privacy Rules.

Other Uses and Disclosures of Protected Health Information: Other uses and disclosures of Protected Health Information that are not described in this Notice will be made only with your written authorization or that of your personal representative. If you authorized the Plan to use or disclose your Protected Health Information, you or your personal representative may revoke that authorization, in writing, at any time. However, the revocation will not be effective with respect to Protected Health Information that the Plan has used or disclosed in reliance on the authorization.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Right to Inspect and Copy your Protected Health Information: In most cases, you have the right to inspect and obtain a copy of your Protected Health Information that is maintained by the Plan. If your Protected Health Information includes an electronic health record (i.e., an electronic record of health-related information created by your health care provider), you have the right to inspect or obtain an electronic copy of your electronic health record. To inspect and copy Protected Health Information, you must submit your request in writing to the Human Resources Department using the Contact Information at the end of this Notice. You may be charged a fee for the costs of copying, mailing or other supplies associated with your request. However, certain types of Protected Health Information will not be made available for inspection and copying. This includes psychotherapy notes, Protected Health Information collected in connection with, or in reasonable anticipation of, any civil, criminal, or administrative action or proceeding, and Protected Health Information that is subject to law that prohibits access to Protected Health Information. In very limited circumstances your request to inspect and obtain a copy of your Protected Health Information may be denied. In that case, you may request that the denial be reviewed. The review will be conducted by an individual chosen by the Plan who was not involved in the original decision to deny your request. The Plan will comply with the outcome of that review.

Right to Amend Your Protected Health Information: If you believe that your Protected Health Information is incorrect or that any important part of it is missing, you have the right to ask for an amendment to your Protected Health Information while it is kept by or for the Plan. You must provide your request and your reason for the request in writing, and submit it to the Human Resources Department using the Contact Information at the end of this Notice. Your request may be denied if it is not in writing or does not include a reason that supports the request. In addition, your request may be denied if you ask for an amendment of Protected Health Information that (1) is accurate and complete; (2) was not created by the Plan, unless the person or entity that created the Protected Health Information is no longer available to make the amendment; (3) is not part of the Protected Health Information kept by or for the Plan; or (4) is not part of the Protected Health Information which you would be permitted to inspect and copy.

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Right to Request Accounting of Disclosures: You have the right to request an accounting for certain uses and disclosures of your Protected Health Information that the Plan made for a period of time up to six years preceding the date of your request. This accounting will not include disclosures the Plan made for treatment, payment, health care operations, for purposes of national security, to law enforcement or to corrections personnel, pursuant to your authorization, directly to you or prior to April 14, 2004. To request an accounting, you must submit your request in writing to the Human Resources Department using the Contact Information at the end of this Notice. Your request must specify the period from which you want to receive a list of disclosures and the form in which you want the accounting to be made (for example, on paper or electronically). The first accounting requested within a 12-month period is free of charge. The Plan may charge you for responding to any additional accounting requests. You will be notified of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions: You have the right to request a restriction or limitation on the uses and disclosures of your Protected Health Information made for treatment, payment or health care operations, or to a person who may be involved in your care or payment for your care. While your request will be considered, the Plan is not required to agree to it. To request a restriction, you must make your request in writing to the Human Resources Department using the Contact Information at the end of this Notice. In your request, you must indicate (1) what information you want to limit; (2) whether you want to limit the Plan's use, disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or parent). The Plan will not agree to restrictions on the uses or disclosures of your Protected Health Information that are legally required or that are necessary to administer the Plan. Where the disclosure is for payment or healthcare operations and the disclosure relates to an item or service for which you paid in full out-of-pocket, the Plan will honor your request to restrict uses and disclosures of your Protected Health Information.

Right to Request Confidential Communications: If you believe that a disclosure of all or part of your Protected Health Information may endanger you, you may request that the Plan communicate with you in an alternative manner or at an alternative location. For example, you can ask that the Plan only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Human Resources Department using the Contact Information at the end of this Notice and specify how or where you wish to be contacted. The Plan will accommodate a request for confidential communications that is reasonable and that states that the disclosure of all or part of your Protected Health Information could endanger you.

Right to Request Paper Copy of this Notice: You have the right to obtain a paper copy of this Notice from the Plan upon request even if you have previously agreed to receive the Notice electronically.

PLAN RESPONSIBILITIES

The Plan is required to provide you this Notice of legal duties and privacy practices with respect to your Protected Health Information as set forth by HIPAA and the Privacy Rules, maintain the privacy of your Protected Health Information, and abide by the terms of the Notice.

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CHANGES TO THIS NOTICE

The Plan is required to abide by the terms of this Notice currently in effect; however, the Plan reserves the right to change the terms of this Notice at any time. The Plan reserves the right to make the revised Notice effective with respect to all Protected Health Information it maintains, including the information maintained before the effective date of the revised Notice, as well as any Protected Health Information that it receives in the future. The effective date of this Notice and any revised Notice may be found on the last page, at the end of this Notice. You will receive a copy of any revised Notice by mail, by e-mail or other electronic means permitted by law. For additional information regarding the Plan's HIPAA Privacy Policies and Procedures, please contact the Plan using the Contact Information described at the end of this Notice.

CHANGES TO THE PLAN'S POLICIES AND PROCEDURES

The Plan also reserves the right to revise its HIPAA Privacy Policies and Procedures and may make the changes effective for all Protected Health Information maintained. The Plan will provide a Notice whenever there is a material change to the Plan’s HIPAA Privacy Policies and Procedures or permitted uses and disclosures.

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 the Plan using the Contract Information at the end of this Notice. All complaints must be submitted in writing. You will not be penalized or subject to retaliation for filing a complaint. If you have questions regarding how to file a complaint, please contact the Plan using the Contact Information at the end of this Notice.

CONTACT INFORMATION

To exercise any of the rights described in this Notice, for more information, or to file a complaint, please contact:

Fordham University 441 East Fordham Road, FMH506 Bronx, NY 10458 Attn: Privacy Officer Tel: 718-817-1000

The effective date of this Notice is January 1, 2019.