medical only enrollment - guidestone/media/insurance/pdf/... · through myguidestone.org, you can...
TRANSCRIPT
SIM-USA
Employee Benefits for
SIM-USA
Dear Participant:
GuideStone is pleased to help SIM-USA provide insurance benefits to meet your needs. You’ll find the information you need to enroll and get the most from your benefit plans.
In this packet, you’ll find:
Important Information, including “How to Get the Most from Your Health Plan”: o Traditional PPO Plans
Benefit information, including:
o Preventive Care Schedule o Summaries of Benefits and Coverage for your plan
Important forms and notices, including your Enrollment Form. Resources to Help You Use Your Plans.
At GuideStone, our mission is to serve those who serve the Lord. We look forward to serving you. If you have any questions about your plans, please speak with your ministry’s authorized Benefits Administrator.
Sincerely,
GuideStone Insurance
Important Information
» Before you receive your ID cards
If you need to see your doctor or fill a prescription before you receive your medical or prescription ID cards, provide the
following information to your provider:
o Medical (Highmark Blue Cross Blue Shield®)
GuideStone group number: CQM363
Member number: (your Social Security number)
Benefit questions: 1-866-472-0924
Hospital or facility admissions: 1-800-452-8507
Claims address:
P.O. Box 1210
Pittsburgh, PA 15230-1210
o Prescription Drugs (Express Scripts)
Member Services: 1-800-555-3432
GuideStone group number: ABSBC01
Rx Bin: 610014
Optional: Visit www.Express-Scripts.com, create your online account and print a temporary ID card.
» Remember to notify your employer immediately if you have any changes in your personal contact
information.
» I need to be admitted to the hospital. Does that have to be pre-authorized?
Yes. Typically, your doctor will handle the pre-authorization process for scheduled admissions. It’s wise to make sure your doctor is handling this at least seven to 10 days prior to your admission. If you’re admitted after an emergency, you need to make sure Highmark is notified within 48 hours of your admission. If neither you nor your doctor’s office completes the required pre-authorization with Highmark, there may be a reduction in benefits for your stay. If you’re unsure whether this process has been completed, you can call Highmark at the toll-free number on the back of your ID card.
This information only highlights the depth of coverage and benefits you can receive when you protect yourself with GuideStone Financial Resources. Limitations and exclusions apply. This material is a general summary of the plans. The official plan documents and contracts set forth the eligibility rules, limitations, exclusions and benefits. These alone govern and control the actual operation of the plan. In the event of a conflict with the description in this material, the terms of the official plan documents and contracts will control. GuideStone Financial Resources of the Southern Baptist Convention reserves the right to change or cancel these programs at any time. This material does not imply an employment contract or guarantee of benefits. Medical underwriting could be required.
Resources to help you use your plan
You have a busy life. Health plans can seem complicated – and the information you want may be hard to find. Here you’ll find information you need to use your health plan – and get the most out of it.
» Important contact info & resources
Want to find a provider? Have a question about a claim? Need a replacement ID card? Here’s the contact information you
need to do all that and much more.
MyGuideStone.org
This is your personalized area (also known as your dashboard) for all your GuideStone products and plans.
Here you can find:
Plan booklets and your plan’s Summary of Benefits, which provide information on what’s covered and how
benefits are paid for your plan. (Want a printed copy? Request one by calling us or e-mailing us at
A summary of your insurance coverage.
Links to plan management resources, including how to find a provider or file a claim.
Much more!
Through myGuideStone.org, you can access Highmark and Express-Scripts for help finding a doctor or hospital, and tracking
medical claims or prescription drugs. Once logged into myGuideStone.org, visit the Insurance tab, then select the Resources
page.
Highmark Blue Cross Blue Shield®- PPO medical coverage
1-866-472-0924
Highmark is your medical claims administrator and network provider. So if you have a question about a medical claim,
want information on what’s covered, to request a new ID card or something similar, you can call Highmark for help.
www.highmarkbcbs.com
Once you register, you can request new ID cards, track claims, compare providers, find wellness support information,
and much more!
Get support for a healthy lifestyle
Visit GuideStone’s wellness website to find GuideStone’s wellness
website, where you’ll find inspirational stories, wellness challenges,
informational articles and resources to help you on the right path.
Check it out at www.GuideStoneInsurance.org/wellness.
Baby BluePrints® Program
1-866-918-5267
Expecting? Highmark’s pregnancy support program is designed to help expectant families understand every stage of
pregnancy and make more informed decisions. Once you enroll, you get support from a nurse Health Coach, a
welcome packet with discount flyers, important prenatal information and vouchers for free gifts!
Express-Scripts Health Solutions – Prescription drug coverage
1-800-555-3432
Express-Scripts is your pharmacy benefits provider. So if you have a question about a prescription drug claim, want
information on what drugs are covered, mail order service, request a new prescription ID card or something similar,
you can call Express-Scripts for help.
www.Express-Scripts.com
Once you register, you can:
Fill new or existing mail order prescriptions.
Track your spending and how close you are to meeting your deductible.
Price a medication and discover cheaper alternatives.
Find generic equivalents for brand name drugs.
Locate participating pharmacies.
SIM Health Choice 3500 Effective January 1, 2015
This chart provides an overview of the benefits and prescription drug program for Health Choice 3500. See the reverse side for a glossary of terms used.
PLAN FEATURES
Deductible for an individual $3,500
Deductible for a family $7,000
Plan pays/individual pays (co-insurance) 80%/20%
Maximum out-of-pocket (medical and prescription): individual/family
(in-network services only, including deductible and co-insurance) $6,350/$12,700
Primary care physician or retail clinic visit co-pay/specialist office visit co-pay $25/$35
Wellness and preventive care co-pay (primary care/specialist) 100% no co-pay
Hospital inpatient (including maternity) 80% after deductible
Outpatient surgery 80% after deductible
Emergency room (per visit) 80% after $100 co-pay
Urgent care co-pay $50
Outpatient services (CT scans, MRI, diagnostic) 80% after deductible
Chiropractic services co-pay (20 visits annually) $35
Mental health and substance abuse: inpatient services 80% after deductible
Mental health and substance abuse: office and professional services co-pay $25
Vision exam co-pay (one exam every 12 months) $25
Deductible for an individual $8,000
Deductible for a family $16,000
Plan pays/individual pays (co-insurance) after deductible 50%/50%
Annual co-insurance maximum for an individual $13,000 after deductible
Annual co-insurance maximum for a family $13,000 after deductible
Wellness and preventive care Not covered
Hospital inpatient (including maternity) 50% after deductible
Outpatient surgery 50% after deductible
Emergency room services: for emergency care only (determined by Highmark) 80% after $100 co-pay
Emergency room services: other than for emergency care only 50% after deductible
Mental health and substance abuse: all services 50% after deductible
Vision exam (one exam every 12 months) 50% after deductible
PRESCRIPTION DRUG PROGRAM1
Generic 80%
Preferred 80%2
Non-preferred 80%2
Generic 80%
Preferred 80%2
Non-preferred 80%2
Specialty drug 80%3
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1 A per-prescription maximum of $250 per 30-day supply applies to retail and specialty drug prescriptions. A per-prescription maximum of $750 per 90-day supply applies to mail-order drug prescriptions.
2 If a preferred or non-preferred drug is purchased when a generic is available, the participant must pay the generic co-pay and the cost difference between the preferred/non-preferred drug and its generic equivalent. The cost difference does not accumulate toward the maximum out-of-pocket limit.
3 One retail fill is allowed after which mail order is required.
Note: This plan does not constitute “creditable coverage”
for Massachusetts residents.
Glossary of terms
Co-insurance — The percentage of eligible claims you pay after you meet your deductible.
Co-insurance maximum, out-of-network — The most you will have to pay in a year in out-of-network co-insurance for covered
benefits after you meet your out-of-network deductible.
Co-pay — The fixed, up-front dollar amount you pay for certain covered expenses. Office visit co-pay amounts do not apply toward your
in-network or out-of-network deductible or your out-of-network co-insurance maximum.
Deductible (family) — This is the amount a family is required to pay before benefits begin for services not covered by co-pays.
Once this amount is met, the plan will consider all family members to have met their deductibles. One individual cannot
contribute more than the individual deductible amount. This is an embedded deductible.
Deductible (individual) — This is the amount an individual is required to pay before benefits begin for services not covered by
co-pays. Once this amount is met, the plan will begin paying claims for that individual at the co-insurance level.
Emergency care — Medical services from the emergency department of a hospital to evaluate a medical condition that, in the absence of
immediate medical attention, would place the health of the individual in serious jeopardy, cause serious impairment to bodily functions or
cause serious and permanent dysfunction to any bodily organ or part.
Generic — A bioequivalent to the brand-name drug made available to the public after the patent has expired on the brand-name
drug. The generic version usually results in a less expensive drug.
In-network — Health care services received from a provider in a network.
Mail order — Mail order is a service that allows you to refill recurring prescriptions (90-day supply) through an online pharmacy.
You receive your prescriptions by mail.
Maximum out-of-pocket (medical and prescription) — The maximum out-of-pocket limit includes the deductible, co-pays and
co-insurance for eligible, in-network services. After the individual or family amount has been satisfied, the health plan covers all
eligible, in-network health care expenses, including co-pays, for the rest of the plan year.
Network provider — A doctor, hospital or other health care facility that has entered into a contract to provide medical services or
supplies at agreed upon rates to you or your covered dependents under the plan.
Non-preferred drugs — A list of prescribed medications that are not on the plan’s formulary.
Preferred drugs — Also known as formulary drugs, this is a list of commonly prescribed, brand-name medications that are selected
based on their clinical effectiveness and opportunities to help control your plan’s costs.
Primary care physician/retail clinic co-pay — The amount you pay for an office visit to a network retail clinic or primary care
physician such as a pediatrician, general practitioner, family practitioner, internist or gynecologist.
Retail pharmacy benefits — This refers to filling your prescriptions at a participating network pharmacy. This approach is best for short-
term prescriptions (up to 30-day). You could save money on co-pays by filling recurring prescriptions via mail order (see above).
Specialist — Any physician not considered a primary care physician.
Urgent care — Treatment at an urgent care facility for the on-set of symptoms that require prompt medical attention.
Vision exam — Covers one annual eye exam per covered family member, which may include an eye health examination, dilation
and/or refraction. Coverage does not include glasses or contact lenses (unless there has been a cataract extraction), eye surgery or
retinal telescreening. See the Preventive Care Schedule for additional vision screening coverage for children when performed by a
pediatrician or primary care physician as part of an annual well-child visit.
Wellness and preventive care — Refers to the services listed on the Preventive Care Schedule, which are covered at 100%, not
subject to the deductible. The Preventive Care Schedule is based on services required under the Patient Protection and Affordable
Care Act of 2010 (PPACA), as amended.
This information only highlights the depth of coverage and benefits you can receive when you protect yourself with GuideStone. There are limitations
and exclusions that apply. This is a general overview of plans that are offered. The official plan documents and insurance contracts set forth the
eligibility rules, limitations, exclusions and benefits. These alone govern and control the actual operation of the plan.
Note: A corresponding Summary of Benefits and Coverage was created to help consumers more easily understand their insurance benefits and
compare plans. To view and download the Summary of Benefits and Coverage documents for all GuideStone medical plans available to you, visit
www.GuideStone.org/Summaries. You may also request printed copies by calling 1-888-98-GUIDE (1-888-984-8433) Monday through Friday,
between 7 a.m. and 6 p.m. CST.
© 2014 GuideStone Financial Resources 25309 10/14
Well child visits (birth–age 18) Preventive schedule
• Wellness exam
• Visual screening
• Hearing screening
• Standard incremental infant checkups for the first 12 months; every 12 months ages 1–18
• Every 12 months ages 3–5; then at ages 6, 8, 10, 12, 15 and 18
• Every 12 months ages 4–6; then at ages 8, 10, 12 and 15
Immunizations: Includes standard childhood immunizations At scheduled ages for each childhood immunization
Adult (age 19+) Preventive schedule Physical examination Every 12 months Pelvic and breast examination Every 12 months Pap test Every 12 months Mammogram (film or digital) Every 12 months after age 39 Prostate cancer screening Every 12 months Urinalysis, venipuncture and CBC Every 12 months Cholesterol screening Every 12 months Glucose testing (for high-risk patients) Every 3 years after age 45
Lung cancer screeningAnnually for adults ages 55–80 years with 30 pack/year smoking history and currently smokes or quit within the past 15 years
Hepatitis B screening For high-risk patients as recommended by your doctor
Bone mineral density screening Every 2 years for women after age 65 and men after age 70
(or younger if high risk for osteoporosis) Colorectal cancer screening: • Fecal occult blood test • Screening with flexible sigmoidoscopy or double-contrast barium enema • Colonoscopy: Includes certain preparations with prescription
As directed by a physician:• Every 12 months after age 50• Every 5 years after age 50• Every 10 years after age 50 (or as recommended by your
doctor if high risk)
Immunizations: Includes expanded age ranges for some immunizations Expanded adult immunizations for at-risk patients
Zoster (Shingles) Adults age 60 and over
Influenza (all ages for children and adults) Every 12 months
Preventive Care ScheduleEffective January 1, 2015The plan pays for preventive care only when given by a network provider. Certain vaccines available at participating pharmacies through Express Scripts. For in-network preventive care, use your Highmark Blue Cross Blue Shield ID card.
© 2014 GuideStone Financial Resources 25140 10/14 8912
Highmark Blue Cross Blue Shield ®Express Scripts ®
Prevention of ObesityObesity places individuals at risk for a number of chronic and debilitating diseases. Highmark is working with physicians, policymakers, The Children’s Health Fund and representatives from the private sector to address the childhood obesity crisis and to create solutions to obesity-related problems. As part of Highmark’s Prevention of Obesity initiative, the following benefits are part of our preventive schedule. For in-network services for the prevention of obesity, use your Highmark BCBS ID card.
Schedule for children Preventive schedule
Children with a body mass index (BMI) in the 85th percentile or higher
• 4 additional preventive office visits• 4 nutritional counseling visits specifically for obesity per year• 1 set of recommended laboratory studies
Schedule for adults (age 18+) Preventive schedule
Adults with a BMI over 30 are eligible for
• 2 additional annual preventive office visits specifically for obesity and blood pressure measurement• Additional nutritional counseling visits specifically for obesity• 1 set of recommended laboratory studies
Birth1
month2
months4
months6
months9
months12
months15
months18
months24
months30
months3
years4
years5
years6
years7
years8
years9
years10
years11
years12
years15
years18
years
Wellness exam 1 ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü ü Every year from ages 11 through 18
Autism screening As recommended by your doctor
Blood pressure ü ü ü ü ü ü ü ü Every year from ages 11 through 18
Visual screening 2, 3 ü ü ü ü ü ü ü ü ü
Hearing screening 2 ü ü ü ü ü ü ü ü
Depression screening Every year beginning at age 11
Fluoride varnish Service provided by the primary care doctor or their staff in the doctor’s office only. As recommended by your doctor for ages 5 years and younger. Benefit does not apply to services provided by a dentist.
Hepatitis B screening When indicated for high-risk as recommended by your doctor
SCREENINGS
Newborn blood screening ü
Lead ü Or when indicated (Please also refer to your state’s specific recommendations.)
Hematocrit or Hemoglobin ü Annually for females during adolescence and when indicated
IMMUNIZATIONS 4 (Includes PA state-mandated benefits)
Hepatitis A 4 Dose 1 Dose 2
Hepatitis B 4 Dose 1 Dose 2 Dose 3(6 to 18 months)
Diphtheria/Tetanus/Pertussis (DTaP) 5 Dose 1 Dose 2 Dose 3 Dose 4
(15 to 18 months)Dose 5
(4 to 6 years)Dose 6
(7 to 10 years, if not fully immunized against pertussis)
Recommended Tdap at 11 to 18 years if 5 or more years have passed since
the child’s last dose of DTP, DTaP or Td
H. Influenzae Type B (Hib) Dose 1 Dose 2 Dose 3 5 Dose 4 (12 to 15 months)
Polio (IPV) 5 Dose 1 Dose 2 Dose 3(6 to 18 months)
Dose 4(4 to 6 years)
Pneumococcal Conjugate (PCV) 5, 6 Dose 1 Dose 2 Dose 3 Dose 4
(12 to 15 months)
Measles/Mumps/Rubella (MMR) 4
Dose 1 (12 to 15 months)
The second dose of MMR is routinely recommended at 4 to 6 years but may be administered during any visit, provided at least 1 month has elapsed since receipt of the first dose and that both doses are administered at or after age 12 months.
Chicken Pox 4 Dose 1 (12 to 15 months)
Dose 2(4 to 6 years)
Children not receiving the vaccine prior to 18 months can receive the vaccine at any time. Children 13 years or older who haven’t been vaccinated and haven’t had chicken pox should receive 2 doses of the vaccine at least 4 weeks
apart. Second dose catch-up is recommended for those who previously received only 1 dose.
Influenza 5 Annually for all children 6 months to 18 years
Meningococcal 1 dose per lifetime beginning at age 11; booster at age 16
Rotavirus Dose 1 Dose 2 Dose 3
Schedule for Children
1 This includes, at appropriate ages, height, weight and body mass index (BMI) measurement and developmental and behavioral assessment, including other care as determined by the doctor. Coverage is based on a calendar year.
2 As shown and when conditions indicate. If patient is uncooperative, rescreen within six months.3 Optometric exams require a vision benefit.4 Children can get this vaccine at any age if not previously vaccinated.5 Another series/schedule may be recommended by your doctor.6 Previously unvaccinated, older infants and children who are beyond the age of the routine infant schedule should follow the dosing
guidelines recommended by their doctor.
Vaccine Express Scripts HighmarkChicken Pox (Varicella) Child Yes
Diphtheria, Tetanus (Td/Tdap) Yes Yes
H. Influenza Type B (Hib) Child Yes
Hepatitis A and B Yes Yes
Influenza Yes Yes
Measles/Mumps/Rubella (MMR) Child Yes
Meningococcal Yes Yes
Pneumococcal Yes Yes
Polio (IPV) Child Child
Rabies, Human Diploid Yes No
Rabies, PF Chick EMB Cell Yes No
Rotavirus Child Child
Shingles (Zoster) Adult Adult
Travel immunizations only through Express ScriptsAnthrax Yes No
Japanese Encephalitis Yes No
Smallpox Yes No
Typhoid Yes No
Yellow Fever Yes No
Medication CoverageAspirin Coverage to persons ages 45 years for men (55 years for women) through 79 years
Fluoride Coverage to persons through the age of 5 years old
Folic acid Coverage to females through the age of 50 years old
Iron Coverage to persons less than 1 year of age
Smoking cessation Coverage to persons age 18 years and older
RaloxifeneTamoxifen
Coverage for women without a cancer diagnosis who are determined to be at risk for breast cancer by their physician and meet certain criteria
Vitamin D supplement Coverage to persons age 65 and older at risk for falls
Preventive MedicationsThe plan pays for preventive care only when given by a network provider. To determine if a specific medication is covered under the wellness benefit, call Express Scripts at 1-800-555-3432. For over-the-counter medications purchased with a prescription from an in-network pharmacy, use your Express Scripts ID card.
Note: This general summary is a reference tool for planning your family’s preventive care and is not a complete list of the Preventive Health Schedule provided under your plan. Your specific needs may vary according to your personal risk factors. Your doctor is always your best resource for determining if you’re at an increased risk for a condition. To determine if a specific procedure is covered under the wellness benefit, call Highmark Blue Cross Blue Shield at 1-866-472-0924.
2015 Preventive Immunization Comparison
Certain immunizations available at participating pharmacies through Express Scripts. Call your local network pharmacy directly to verify immunization availability, minimum age requirements and if a prescription is required.
Maternity
You should expect to receive the following screenings and procedures:• Hematocrit and/or Hemoglobin (Anemia)• Urine Culture & Sensitivity (C & S)• Rh typing during your first visit• Rh antibody testing for Rh-negative women• Hepatitis B with immunization, if needed• Tdap with every pregnancy
In addition, your doctor may discuss breastfeeding during weeks 28 through 36 and/or post-delivery, tobacco use and behavioral counseling to reduce alcohol use.
Note: This schedule is based on services required under the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended, including expanded women’s preventive health services such as approved contraceptives, gestational diabetes screening and breastfeeding support. GuideStone does not provide coverage for abortions or abortion-inducing drugs or devices, as this violates our Biblical convictions on sanctity of life. This schedule is reviewed and updated periodically based on the advice of the U.S. Preventive Services Task Force and according to clinical guidelines established by national medical organizations. Your specific needs for preventive services may vary according to your personal risk factors. Your doctor is always your best resource for determining if you’re at increased risk for a condition. Some services may require prior authorization. If you have questions about this schedule or prior authorizations, please call the Member Service number on the back of your ID card.
SERVICES
Contraception and counseling All women with reproductive capacity: patient education, counseling and certain Food and Drug Administration (FDA)-approved contraceptive methods*, including sterilization and procedures as prescribed
Well-woman visits Up to 4 visits annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and the first visit to determine pregnancy
SCREENINGS/PROCEDURES
Gestational diabetes screening All women: between 24 and 28 weeks of gestation/High-risk: at the first prenatal visit
Interpersonal and domestic violence screening and counseling
Annually
Lactation (breastfeeding) counseling, support and supplies
Comprehensive lactation support and counseling by a trained provider during pregnancy and/orin the postpartum period and costs for renting breastfeeding equipment
Women’s Health Preventive Schedule
* GuideStone will not provide coverage for abortion services or abortion-inducing drugs or devices such as Ella and Plan B, as this violates our Biblical convictions on sanctity of life. GuideStone covers certain non-abortive, generic contraceptives under the Preventive Care Schedule.
Because the Children’s Health Insurance Program (CHIP) is a government-sponsored program and not subject to PPACA, certain preventive benefits may not apply to CHIP members and/or may be subject to co-payments.
You and your dependents enrolled in a GuideStone medical plan through
Highmark Blue Cross Blue Shield® have a vision exam benefit. It is different
from vision insurance. This flier will help you understand what is covered, what
is not covered, the differences in vision services and how to find a network
vision provider.
What is covered under your vision exam benefit?
Your vision benefit covers one annual eye exam per covered family member. It’s
important to have an eye exam to determine if you need glasses or contacts or
have eye conditions or diseases. Your eye exam may include:
• Eye health examination: Your doctor will evaluate your vision and
check for eye diseases through specialized diagnostic equipment
and lights.
• Dilation: Your doctor may use drops to enlarge your pupils.
Through dilation, your doctor will be able to examine the inside of
your eyes with lights and instruments.
• Refraction: If you need corrective lenses, your doctor will conduct a
refraction assessment using a computerized refractor to estimate
your prescription. While flipping between lenses, your doctor will
often ask, “Which is better: one or two? Three or four? This or that?”
Understanding Your Vision Exam Benefit
Your annual eye exam is an in-network benefit.
If you use an in-network provider (see “How can I find a covered vision provider?” on the next page), you will be charged a
primary care office visit co-pay. If you receive care from an out-of-network provider or are on a Health Saver medical plan, you
will be required to pay your deductible first and then your co-insurance percentage.
What is not covered under your vision exam benefit?
Your vision benefit does not include coverage for glasses or contact lenses unless you’ve had a cataract extraction. Your vision
benefit does not cover eye surgery (radial keratotomy or laser) to correct nearsightedness, farsightedness or astigmatism.
Retinal telescreening by digital imaging is not covered as part of a routine comprehensive exam but could be covered for
patients with diabetes.
Five tips For healthy eyes
ONE. Eat a well-balanced diet for nutrients (omega-3, vitamins C and E) and to maintain a healthy weight.
TWO. Wear sunglasses to protect against harmful UV rays.
THREE. Use safety glasses or a mask when working on house projects or playing sports.
FOUR. Avoid strain by taking a break from your TV or computer screen.
FIVE. Visit your eye doctor for your annual eye exam.
5
1-888-98-GUIDE • www.GuideStone.org © 2013 GuideStone Financial Resources 22959 9/13 8879
Effective January 1, 2014
Your Health PlanHow to Get the Most from
G r o u p P l a n s – H i g h m a r k B l u e C r o s s B l u e S h i e l d
Contact Information
1-888-98-GUIDE (1-888-984-8433) www.GuideStoneInsurance.org2 1-888-98-GUIDE (1-888-984-8433) www.GuideStoneInsurance.org2
savingstipUsing in-network providers saves you money in two ways:
- The amount you and the plan have to pay may be reduced up to 50% thanks to provider discounts.
- You have a higher level of benefits when you use in-network providers.
Welcome to your GuideStone health plan. We count it a joy to provide you with insurance benefits that give you value and share your values. This booklet helps you navigate your health plan by providing contact information and answers to frequently asked questions. We’ve also included several savings tips to help your family find more value in your medical plan.
Your Health PlanHow to Get the Most from
GuideStone Financial Resources
If you have a general question about your plan or need help finding information, contact your employer’s authorized benefits representative. You can log into www.MyGuideStone.org to download your plan booklet and Summary of Benefits and Coverage. You can also access the Highmark Blue Cross Blue Shield and Express Scripts websites.
Highmark Blue Cross Blue Shield®
Highmark is your medical network provider and claims administrator. They can answer your questions on what’s covered and medical claims. And Highmark can provide you with a new medical ID card.
Call Highmark at 1-866-472-0924.
Log into www.HighmarkBCBS.com to find doctors and health care facilities participating in the BCBS PPO network. You can also view your claims, spending and benefits.
Medical ID card: When you enroll in a new GuideStone medical plan, you receive a medical ID card from Highmark. The member and each dependent receives a medical ID card with their name and the primary member’s name.
3
Contact Information
Express Scripts®
Express Scripts is your pharmacy benefits administrator. They can answer your questions on prescription drug claims, which drugs are covered and the mail-order service. And Express Scripts can provide you with a new prescription drug ID card.
Call Express Scripts at 1-800-555-3432.
Log into www.Express-Scripts.com to price medications, ship your medications to your home at no cost through the mail-order service, find generic equivalents for brand-name drugs and track your spending.
Prescription drug ID card: When you enroll in a new GuideStone medical plan, you receive a prescription drug ID card from Express Scripts. Two ID cards will be sent to each household, but both cards only list the primary member’s name. The dependent(s) is not listed. Show your ID card to your pharmacist to receive prescription drug discounts.
1-888-98-GUIDE (1-888-984-8433) www.GuideStoneInsurance.org
savingstipExpress Scripts’ website has several resources to help save you money, including:
- The “Price a Medication” tool shows you how much you could save by filling a generic drug instead of a brand-name drug and ordering through the mail-order service.
- The “My Rx Choices” tool shows your current prescriptions and generates lower-cost choices for you. You can also search by drug name to see potential savings by using a comparable, lower-cost drug.
- The mail-order pharmacy helps people who regularly fill prescriptions by offering a 90-day supply, greater savings and free delivery.
Frequently asked questions
savingstipChoose generic drugs when appropriate. If a brand-name drug is purchased when a generic is available, you must pay the generic co-pay plus the difference between the cost of the brand-name and generic drug.
1-888-98-GUIDE (1-888-984-8433) www.GuideStoneInsurance.org
How much are my co-pays?
You can find your medical plan co-pay amounts — office visit, urgent care, specialist and emergency room — listed on your medical ID card. Prescription drug co-pays vary by the type of drug — generic, preferred, non-preferred or specialty. To find out how your prescriptions are classified and how much they’ll cost, log into www.Express-Scripts.com and select “Price a medication.”
What if the cost of the drug at my retail pharmacy is less than my prescription co-pay?
You pay the lesser of the two costs. For example, if the cost of the drug at your local pharmacy is $4 and your applicable co-pay is $15, you pay $4.
What is a deductible?
A deductible is the amount you pay out-of-pocket before your co-insurance benefits begin. You must meet your deductible with eligible charges, such as a hospital admission or an outpatient surgery, before your claims are paid. Some services, such as office visits, are covered by co-pays and are not subject to the deductible. Co-pays do not count toward meeting the deductible but do count toward your maximum out-of-pocket.
No one family member is responsible for more than the individual deductible on your plan. Once a family member meets the individual deductible, GuideStone starts paying co-insurance according to plan benefits for that individual. Other family members must continue to pay toward the remaining family deductible until it is met.
What is co-insurance?
Co-insurance is the amount (usually shown in a percentage) you pay for claims after you meet your deductible. Your plan pays for some of your claims and you pay the rest. Your in-network co-insurance amounts apply toward the maximum out-of-pocket and your out-of-network co-insurance amounts apply toward the co-insurance maximum.
How does my maximum out-of-pocket work?
Your out-of-pocket health care costs will be capped for eligible, in-network medical and prescriptions services. The maximum out-of-pocket limit, required by health care reform, is the total amount of eligible, in-network medical and prescription services you will pay. The in-network deductible, co-pays and co-insurance for eligible, in-network services count toward the limit. Once you reach this amount, the health plan covers all eligible, in-network health care expenses, including co-pays, for the rest of the plan year. Out-of-network expenses accumulate separately and do not contribute to the maximum out-of-pocket limit.
4
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What is Prior Authorization for prescriptions?
Prior Authorization is required on a small percentage of drugs. It helps make sure each patient receives the appropriate medication at the right time. If your doctor prescribes a drug that requires Prior Authorization, an Express Scripts pharmacist will discuss the prescription with your physician. If you’re currently taking medication for which you’ve already received Prior Authorization, contact Express Scripts to discuss how changing plans may impact your Prior Authorization. Or if you have questions about Prior Authorization, please contact Express Scripts.
What kind of wellness benefits are covered on my health plan?
Wellness benefits, such as preventive care screenings, annual physicals and immunizations, are included in your GuideStone medical plan. These benefits are based on Highmark’s Preventive Care Schedule. Eligible, in-network wellness services are covered at 100%, do not require a co-pay and are not subject to the deductible. There is no annual maximum benefit. Wellness services received from providers outside the PPO network are not covered.
Do GuideStone health plans cover maternity care?
Yes, all of our health plans include maternity coverage. There are no waiting periods for maternity benefits. Highmark offers an education and support program called Baby BluePrints®. This program is designed to help expectant families better understand every stage of pregnancy and make more informed care and lifestyle-related decisions. To enroll in Baby BluePrints, call Highmark at 1-866-918-5267.
When do I need to add my newborn or adopted child to my health plan?
To make sure your claims are properly processed and the child is added to your health plan, you need to add the dependent child within 60 days of the child’s birth, adoption or placement for adoption. Contact your benefits administrator to add your newborn or adopted child.
1-888-98-GUIDE (1-888-984-8433) www.GuideStoneInsurance.org
savingstipThrough Express Scripts’ $4 Generic Prescription Drug Program, you can use your prescription drug ID card to pay the $4 co-pay for approved generic drugs at select retail pharmacies.
Frequently asked questions Continued
6 1-888-98-GUIDE (1-888-984-8433) www.GuideStoneInsurance.org
What if I need medical attention while I’m traveling?
If you’re going on a road trip, short-term mission trip or traveling internationally, you have coverage across the U.S. and overseas. In the U.S., you’re covered by a nationwide network, and you can search for providers just as you would at home. If you need to be hospitalized, call the number on the back of your medical ID card for pre-certification or pre-authorization.
Outside of the U.S., your plan includes international coverage. You have access to doctors and hospitals in more than 200 countries around the world through BlueCard Worldwide®. For information about the program, call toll-free 1-800-810-BLUE (1-800-810-2583).
How do I know my claims were paid?
Explanations of Benefits (EOBs) are mailed to you after you receive treatment and a claim is filed. You can also opt to receive your EOBs by mail and online or online only. EOBs explain how benefits were paid under your health plan.
Do I have a vision benefit?
Yes. Your PPO medical plan includes a vision exam benefit. You can receive an annual eye exam for each participant, including an eye health examination, dilation and refraction. This falls under the primary office visit co-pay for care received from an in-network provider. Out-of-network care will be covered at the out-of-network deductible and co-insurance levels. To find an in-network vision provider, visit Highmark’s website and use the “Find a Doctor, Hospital or Other Medical Provider” tool. Do not use the “Find an Eye Care Provider” tool because it will render incorrect results under this benefit.
Enrollment Form Group Plans
GENERAL INFORMATION (ALL SPACES MUST BE COMPLETED)
Employer name: SIM-USA Employer number: 72738
Employee name-Last: __________________________________________ First: _____________________________ MI: _____________
Birth date: ______/______/________ Social Security number: ______________________________________________________________
Home address:____________________________________________________________________________________________________
City: _______________________________________________________________ State: _____ ZIP Code: _________________________
Daytime telephone: (______)___________________________ E-mail: ________________________________________________________
Sex: Male Female Marital Status: Married Single
Employee classification:_________________________________
Monthly salary: $____________ Date of full-time employment: ______/______/________ Coverage effective date: ______/______/________
MEDICAL
For myself: yes no For spouse: yes no For eligible children: yes no
Coverage
Health Choice 3500 80/20
PARTICIPANT & DEPENDENT* INFORMATION (ONLY LIST FAMILY MEMBERS TO BE COVERED
Last name First name Initial Social Security
number Relationship Birth date Gender M/F Medical Yes/No
————— Self ———— —
* Your spouse and children up to age 26 are eligible for coverage.
REQUIRED SIGNATURES
I authorize my employer to arrange for me to be covered under the terms of the plans I have chosen. I also authorize my employer to make any required deductions from my earnings as my contribution to the cost of this coverage.
Employee signature: ___________________________________________________________________________ Date: ______/______/________
Employer representative: _______________________________________________________________________ Date: ______/______/________
GUIDESTONE USE ONLY
Processed by:____________________________________ Date: ____/____/______ Letter:_______
Waiver of Medical
Group Plans For new Group Plans participants: If coverage is fully paid for by your employer,you must complete this form to waive (decline) medical
coverage for both you and your dependents under Group Plans.
For existing Group Plans participants: If you waive medical coverage in which you and/or your dependents are already enrolled, one of the
following applies:
• For employer-paid coverage (employee only coverage or employee, dependent or family coverage): Paid coverage will end on the last day
of the month if GuideStone receives your completed waiver form by the 20th of the month.
• For employee-paid coverage (dependent coverage): Coverage will end on the last day of the month through which the employee has paid
for coverage (“paid-through date”). Please provide the “paid-through date” in the section below.
CERTIFICATION AND WAIVER________________________________________________________________________________________
Employer:_SIM-USA_______________________________________ Employer number: 72738 ______________
Employee name:____________________________________________________ Social Security number (last four digits):________________
This is to certify that I have been given the opportunity to apply for or continue medical coverage provided to me and/or my dependents at no
cost to me by my employer. My employer has not provided or indicated that it will provide any financial or other incentive whose primary
purpose is to cause me to waive coverage. I understand that my dependents are not eligible for coverage if I waive coverage for myself.
I waive medical coverage for: Reason for waiving:
Myself Other group medical coverage
Myself and all eligible dependents Other individual medical coverage
All eligible dependents Other (explain):________________________________
Only these dependents:
Social Security number (last four digits):___________________ Name:_________________________________________________________
Social Security number (last four digits):___________________ Name:_________________________________________________________
Social Security number (last four digits):___________________ Name:_________________________________________________________
I understand that if I ask for coverage later, the terms of the plans will control my ability to get coverage. I also understand that waiting
periods and other limitations may apply.
Employee signature:_____________________________________________________________________________ Date: ____/____/______
Employer representative:__________________________________________________________________________ Date:____/____/______
Special enrollees for medical coverage: Under federal law, if you decline enrollment for medical coverage for yourself or your dependents
because of other medical (not dental) coverage, you may in the future be able to enroll yourself or your dependents as special enrollees in
Group Plans. Also, if you acquire a new dependent due to marriage, birth, adoption or placement for adoption, you may be able to enroll
yourself and your dependents as special enrollees. To enroll as a special enrollee for medical coverage, you must request enrollment within
60 days after your other coverage ends or within 60 days after the marriage, birth, adoption or placement for adoption. These rules do not
apply for dental coverage.
Late enrollees: If you or your dependents do not enroll when first eligible or as a special enrollee as described above, you or your
dependents may enroll as late enrollees under the plans. You may enroll as a late enrollee for medical coverage during any
re-enrollment period. Coverage will become effective on the January 1 after GuideStone receives your enrollment form.
Note: Please see the plan booklets for information about waiting periods and other limitations for special and late enrollee
Notice of Special Enrollment Rights
You are eligible to participate in GuideStone‘s group health plans. To participate, you must enroll and pay the costs if required by your
employer. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes provisions for workers and dependents that
allow you to have special enrollment rights should you acquire a new dependent or if you decline coverage under this plan for
yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons.
HIPAA allows you special enrollment rights in GuideStone’s group health plans according to the following guidelines:
Loss of other coverage (excluding Medicaid or a State Children’s Health Insurance Program)
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group
health plan coverage is in effect, you may be able to enroll yourself and your dependents in this plan if you or your dependents
lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage).
However, you must request enrollment within 60 days after your or your dependents’ other coverage ends (or after the employer
stops contributing toward the other coverage).
Loss of coverage for Medicaid or a State Children’s Health Insurance Program
If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a
State Children’s Health Insurance Program is in effect, you may be able to enroll yourself and your dependents in this plan if you
or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your
dependents’ coverage ends under Medicaid or a State Children’s Health Insurance Program.
New dependent by marriage, birth, adoption or placement for adoption
If you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself
and your new dependents. However, you must request enrollment within 60 days after the marriage, birth, adoption or placement for
adoption.
Eligibility for Medicaid or a State Children’s Health Insurance Program
If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or
through a State Children’s Health Insurance Program with respect to coverage under this plan, you may be able to enroll
yourself and your dependents in this plan. However, you must request enrollment within 60 days after your or your dependents’
determination of eligibility for such assistance.
Important Warning
If you decline enrollment for yourself or for an eligible dependent, GuideStone may require that you complete the Waiver of Medical
Coverage form. If you do not complete the form, you and your dependents may not be entitled to special enrollment rights upon a
loss of other coverage as described above, but you will still have special enrollment rights when you have a new dependent by
marriage, birth, adoption or placement for adoption, or by virtue of gaining eligibility for a state premium assistance subsidy from
Medicaid or through a State Children’s Health Insurance Program with respect to coverage under this plan, as described above. If
you do not gain special enrollment rights upon loss of other coverage, you cannot enroll yourself or your dependents in the plan
at any time other than the plan’s annual open enrollment period, unless special enrollment rights apply because of a new
dependent by marriage, birth, adoption or placement for adoption, or by virtue of gaining eligibility for a state premium assistance
subsidy from Medicaid or through a State Children’s Health Insurance Program with respect to coverage under this plan.
To request special enrollment or to obtain more information about the plan’s special enrollment provision contact your
employer’s authorized representative or call GuideStone at 1-888-98-GUIDE (1-888-984-8433).
© 2014 GuideStone Financial Resources 23658 02/14 8136
Privacy Practices of Health Plans
This Notice describes how medical information about you may be used and disclosed by the Plans and how you can get access to this information. Please review it carefully.
» Summary of Privacy Notice
GuideStone Financial Resources of the Southern Baptist Convention is the plan sponsor of the self-funded Group and Personal health plans (Plans) that are subject to the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA).
This notice does not apply to Protected Health Information maintained in your employment records by your employer for employment or other non-health plan purposes.
» How the Plans will use your information
The plans may use and disclose your Protected Health Information without authorization from you to pay medical benefits or operate the Plans. The Plans may also use, share or disclose your Protected Health Information in connection with treatment by a health care provider covered by HIPAA. In addition, the Plans may use or disclose your information in other special circumstances described in this notice. The Plans will require your written authorization for the use or disclosure of your Protected Health Information for any other purpose.
» Your individual rights
You have the right to access certain Protected Health Information, inspect and copy this information, amend or correct the information, request restrictions on the use and disclosure of the information, request the communications be made to you through alternate means or an alternative location, and obtain an accounting of the information that the Plans have accessed or disclosed for reasons other than treatment, payment, health care operations or in certain other circumstances, and to obtain a paper copy of the Privacy Notice.
» Questions and complaints
You may contact the following person for more information about the Plans’ privacy practices, to exercise your rights or to complain about how the Plans are handling your Protected Health Information:
HIPAA Privacy Contact
GuideStone Financial Resources
2401 Cedar Springs Road
Dallas, TX 75201-1498
1-888-98-GUIDE (1-888-984-8433)
The attached notice describes all of the Plans’ privacy practices in more detail.
» Notice of privacy practices of health plans
This Notice describes how medical information about you may be used and disclosed by the Plans named below and how you can get access to your information. Please review it carefully.
GuideStone Financial Resources is the plan sponsor of the Group and Personal self-funded health plans (Plans) that are subject to the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA).
The privacy of your Protected Health Information that is created, used, or disclosed by the Plans is protected by HIPAA. The plans are required by law to:
maintain the privacy of your Protected Health Information.
provide you with this notice of the Plans’ legal duties and privacy practices with respect to your Protected Health Information.
abide by the terms of this notice.
Plan uses and disclosures for treatment, payment or health care operations
Under HIPAA, the Plans and the individuals who administer them may use and disclose your Protected Health Information for treatment, payment or health care operations without obtaining a written authorization from you. This broad range of activities includes:
Treatment. The Plans may disclose Protected Health Information to your providers for treatment, including the provision of care (diagnosis, cure, etc.) or the coordination or management of that care.
Payment. The Plans may use and disclose your Protected Health Information for enrollment, to receive payment for coverage and to pay benefits. Payment activities include receiving claims or bills from your health care providers, processing payments, sending explanations of benefits (EOBs) to the Plan member, reviewing the medical necessity of the services rendered, conducting claims appeals and coordinating the payment of benefits between multiple medical plans.
Health care operations. The Plans may use and disclose your Protected Health Information for activities compatible with and directly related to treatment and payment. For example, the Plans may use or disclose your Protected Health Information for the Plans’ administration activities such as quality assessments, case management, disease-management programs and other Plan-related activities including audits of claims.
Our Plans contract with other businesses for certain Plan administration services. Our third-party administrator provides underwriting for Group and Personal plans. The third-party administrator provides claims processing services for the Plans. The Plans may release your health information to one or more of these “business associates” for these purposes if the business associate agrees in writing to protect the privacy of your information.
Unless you authorize the Plans otherwise (or the individual identifying data is deleted from the information), your Protected Health Information will be available only to the individuals who need the information to conduct Plans’ administration activities and the release will be limited to the minimum disclosure required unless otherwise permitted or required by law.
Other uses and disclosures permitted and required by the Plans
In the following circumstances the Plans may be required or permitted to use or disclose your Protected Health Information without obtaining an authorization from you. These events are generally subject to certain conditions. More specific information is available from the Privacy Contact upon request.
Required by law. The Plans may be required by law to release your Protected Health Information to a government or public health representative. The disclosure must comply with the relevant requirements of that law and be limited to the information that is required.
Public health. The Plans are permitted to disclose your Protected Health Information for certain required public health activities to:
a public health authority that is authorized to collect or receive that information for the purpose of preventing or controlling disease, injury or disability.
a public health authority or other governmental authority authorized to receive reports of child abuse or neglect.
a person subject to the jurisdiction of the Food and Drug Administration (FDA) for activities related to the quality, safety or effectiveness of FDA-regulated products or activities.
a person who may have been exposed to a communicable disease or is otherwise at risk for contracting or spreading a disease or condition, where authorized by law as necessary in the conduct of a public health intervention or investigation.
Victims of abuse, neglect or domestic violence. The Plans may use and disclose your Protected Health Information to a government authority if the Plans reasonably believe you are a victim of abuse, neglect or domestic violence and such disclosure is required by law, or if the Plans, in the exercise of its professional judgment, believe the disclosure is necessary to prevent serious harm to you or other potential victims.
Health oversight activities. The Plans may use and disclose your Protected Health Information to a health oversight agency for oversight activities authorized by law, including audits, civil, administrative or criminal investigations, actions or proceedings, and certain other oversight activities.
Judicial and administrative proceedings. The Plans may use and disclose your Protected Health Information in the course of any judicial or administrative proceeding in response to a court or administrative tribunal’s order, subpoena, discovery request or other lawful process. The Plans will only disclose information in response to a lawful process other than a court or administrative tribunal order if satisfactory assurances are received from the party seeking the information that notice of the request has been provided to you and that you have not filed an objection within the time provided for you to do so or that appropriate processes have been followed.
Law enforcement purposes. The Plans may use and disclose certain Protected Health Information for a law enforcement purpose to a law enforcement official if certain legal conditions are met. For example, in certain situations, information may be disclosed to a public official where you are suspected to be a victim of a crime.
Decedents. The Plans may use and disclose your Protected Health Information to a coroner or medical examiner or to a funeral director for the purpose of carrying out his or her duties as authorized by law.
Organ/eye/tissue donation. If you are an organ donor, the Plans are permitted to use and disclose your Protected Health Information to an appropriate entity for cadaveric organ, eye or tissue donation and transplantation purposes.
Certain limited research activities. If the Plans obtain documentation from the individual or from a researcher that the applicable authorization requirement has been waived by an appropriate Institutional Review Board or privacy board, the Plans may use and disclose your Protected Health Information for research purposes.
Health and safety. The Plans may use and disclose your Protected Health Information to avert a serious threat to the health or safety of you or any other person, consistent with applicable law and standards of ethical conduct.
Government functions. The Plans may use and disclose your Protected Health Information for specialized government functions, for example, if you are in the Armed Forces or a veteran for purposes of certain national security, Presidential protection and intelligence activities.
Workers’ Compensation. The Plans may use and disclose your Protected Health Information as authorized by and to the extent necessary to comply with laws and regulations related to workers’ compensation or similar programs.
» Specific uses and disclosures
The Plans may also use and disclose your Protected Health Information for the following specific purposes:
Communications related to your health. The Plans may use and disclose your Protected Health Information to provide information to you about disease management programs, treatment alternatives or other health-related benefits and services that may be of interest to you.
Plan sponsor. The Plans may disclose your Protected Health Information to GuideStone for reasons consistent with the Privacy Rules of HIPAA and as described in the Plans’ documents.
» Limitations on use and disclosure
If a use or disclosure of your Protected Health Information identified in this notice is subject to a law more stringent than HIPAA, the more stringent law will apply. If you have a question about your rights under any particular federal or state law, please write to the HIPAA Privacy Contact at the provided address.
» Authorizations required for all other uses and disclosures
Any other use or disclosure of your Protected Health Information not identified within this notice will be made only with your written authorization. You have the right to limit the type of information and the persons to whom it should be disclosed. You may revoke your written authorization at any time, and the revocation will be followed to the extent action on the authorization has not yet been taken. An authorization form is available by calling 1-888-98-GUIDE (1-888-984-8433) or from GuideStone’s website, www.GuideStoneInsurance.org.
» Your rights
You have the right to:
request a restriction on certain uses and disclosures of your Protected Health Information by the Plans. The Plans are not required to agree to a requested restriction for payment or health care operations where the health care provider has not been paid out of pocket in full. To request a restriction, please write to the HIPAA Privacy Contact and provide specific information as to the disclosures that you wish to restrict and the reasons for your request. The Plans will respond in writing.
request that the Plans’ confidential communications of your Protected Health Information be sent to alternative locations or by alternative communicative means. For example, you may ask that we send all explanation of benefits statements (EOBs) to your office rather than your home address. The Plans are not required to accommodate your request unless the request is reasonable and you state that the Plans’ ordinary communication process could endanger you.
inspect and obtain a copy of the Protected Health Information by making a written request that may be used by the Plans to make decisions about your benefits. Access to psychotherapy notes, information compiled in a reasonable anticipation of or for use in legal proceedings may be denied. A reasonable, cost-based fee may be imposed for copying and mailing the requested information.
request that the Plans amend your Protected Health Information or record if you believe the information is incorrect or incomplete.
receive an accounting of certain access to or disclosures made of your Protected Health Information for purposes other than treatment, payment or Plans operations in the six years prior to the date of the request.
request and obtain a paper copy of this notice at any time, even if you have agreed to receive it electronically.
receive notification in the event the Plans discover a breach of your unsecured Protected Health Information and determine notification is required under HIPAA.
To exercise these rights, please write to the HIPAA Privacy Contact at the provided address. There are circumstances where the Plans are allowed to deny or limit your requests. In such event, you may have the right to object and obtain a review of the Plans’ decision. The Plans will provide you with further information about those rights at that time. If you would like more specific information about these matters, contact the HIPAA Privacy Contact.
» Changes to this notice
Each Plan reserves the right to change the terms of this notice and its information practices and to make the new provisions effective for all Protected Health Information it maintains. Any amended notice will be made available to you.
» Complaints and privacy contact
You may file a complaint with the Plans’ HIPAA Privacy Contact and with the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by any Plan. Their addresses are available under contact information. All complaints must be filed in writing. You will not be retaliated against for filing a complaint.
» Privacy contact information
If you have any questions about this notice, please contact the HIPAA Privacy Contact:
HIPAA Privacy Contact
GuideStone Financial Resources
2401 Cedar Springs Road
Dallas, TX 75201-1498
1-888-98-GUIDE (1-888-984-8433)
To contact the Secretary of Health and Human Services, write to:
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll free: 1-877-696-6775
www.hhs.gov/contacts
© 2012 GuideStone Financial Resources 21167 12/12