Drugs

Further information

was relied upon in making the benefit determination o Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination o Constitutes a statement of policy or guidance with respect to the Plan concerning the denied benefit for your diagnosis, regardless of whether such statement was relied upon in making the benefit determination • A review that takes into account all comments, documents, records and other information submitted by you related to the claim, regardless of whether the information was submitted or considered in the initial benefit determination • A review that does not defer to the initial adverse benefit determination and that is conducted neither by the individual who made the adverse determination, nor that person’s subordinate • A review in which the named fiduciary consults with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was neither consulted in connection with the initial adverse benefit determination, nor the subordinate of any such individual. This applies only if the appeal involves an adverse benefit determination based in whole or in part on a medical judgment (including whether a particular treatment, drug or other item is experimental) • The identification of medical or vocational experts whose advice was obtained in connection with the adverse benefit determination, regardless of whether the advice was relied upon in making the decision Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 243 • In the case of a claim for urgent care, an expedited review process in which: o You may submit a request (orally or in writing) for an expedited appeal of an adverse benefit determination o All necessary information, including the Plan’s benefit determination on review, will be transmitted between the Plan and you by telephone, facsimile or other available similarly prompt method. You must use and exhaust Plans’ administrative claims and appeals procedure before bringing a suit in federal court. Similarly, failure to follow the Plans’ prescribed procedures in a timely manner will also cause you to lose your right to sue under ERISA 502(a) regarding an adverse benefit determination. If you have exhausted your administrative claim and appeal procedures, you may only bring suit in a federal district court if you file your action or suit within two years of the date after the adverse benefit determination is made on final appeal. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 244 Appealing a Denial — Retiree Value Plus Option This information regarding appeals is for the above referenced non-grandfathered plan. This contains revised appeal information and requirements specific to the Retiree Value Plus Option. The Patient Protection and Affordable Care Act (PPACA) has changed the rules, requirements and procedures for the processing of group health plan claims and for the reevaluation and determination of adverse benefit determinations (i.e., appeals), to be effective on July 1, 2011; however, there are other rules and provisions that the U.S. Department of Labor is currently reviewing. Those rules carry a compliance date of January 1, 2012. American Airlines, Inc.-sponsored health and welfare benefit plans are, we believe, in compliance with the U.S. Department of Labor’s regulations as of their most recent interpretation and guidance. As the U.S. Department of Labor and the U.S. Department of Health and Human Services continue to provide updated regulations, clarification and guidance on these claim procedures, American Airlines, Inc., as sponsor and administrator of its health and welfare benefit plans, will modify its claim and appeal procedures to comply with these regulations, and will incorporate those regulations in this Guide in a timely manner in compliance with the federal regulations, guidance and interpretation. Procedures for Appealing an Adverse Benefit Determination As a participant in the Company-sponsored health and welfare benefit plans, you have the right to appeal adverse benefit determinations. Adverse benefit determinations include denial, withholding and reduction of benefits described in the plans, and eligibility/enrollment determinations that prevent you or your dependents from obtaining coverage under the plans. Adverse benefit determinations also include rescission of coverage (whether or not the rescission has an adverse effect on any particular benefit at the time). American Airlines, Inc., as Sponsor and Administrator for the Company-sponsored health and welfare benefit plans, has a two-tiered appeal process — referred to as First Level and Second Level Appeals. First Level Appeals are conducted by the claims processor or benefit administrator that rendered the adverse benefit determination. Second Level Appeals are conducted by the Pension Benefits Administration Committee (PBAC) at American Airlines, Inc. This two-tiered appeal process applies to adverse benefit determinations made on all self-funded benefits or plans, as follows: • Retiree Standard Medical Option • Retiree Value Plus Option • Supplemental Medical Plan and for administrative, eligibility and enrollment issues on any and all benefits or plans offered through the benefit program for Retirees. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 245 With respect to adverse benefit determinations made on fully insured benefits, as follows: • Retiree Life Insurance Benefit, and • Long Term Care Insurance Plan, the appeal process is defined by the respective insurers (thus, it might not be a two- tiered process). The PBAC cannot render a decision involving fully insured benefits (except for administrative, eligibility and enrollment issues, as stated previously). The insurers make the final appeal determinations for their respective insured coverages/benefits. Each insurer has its own appeal process and you should contact the respective insurer for information on how to file an appeal (see “Contact Information” in the Reference Information section). This two-tier appeal process is mandatory for all claims, unless otherwise stated. The one exception to this mandatory two-tier process is an appeal for an urgent care claim. For urgent care claim appeals, only Second Level Appeals are required. No First Level Appeals are necessary. Retirees must use both levels of appeal (or the Second Level Appeal for urgent care claims) and must exhaust all administrative remedies to resolve any claim issues. If you receive an adverse benefit determination, you must ask for a First Level Appeal review from the claims processor or benefit administrator. You or your authorized representative has 180 days following the receipt of a notification of an adverse benefit determination within which to file a first Level Appeal. If you do not file your First Level Appeal (with the claims processor or benefit administrator) within this time frame, you waive your right to file the First and Second Level Appeals of the determination. To file a First Level Appeal with the claims processor or benefit administrator, please complete an Application for First Level Appeal and include with the Application all comments, document, records and other information relating to the denied/withheld benefit. (The Application for First Level Appeal provides information about what to include with your appeal). The claims processor or benefit administrator will review your First Level Appeal and will communicate its First Level Appeal decision to you in writing, • For pre-service claims – within 30 days of receipt of your First Level Appeal • For post-service claims – within 60 days of receipt of your First Level Appeal • For urgent care claims – within 72 hours of receipt of your First Level Appeal • For all other claims for all benefits other than medical, within 60 days of receipt of your First Level Appeal, if the claims processor or benefit administrator requires additional time to obtain information needed to complete your First Level Appeal for non-medical benefits, it may have an additional 60 to complete your First Level Appeal (the claims processor or benefits administrator will notify you that this additional time period is needed to complete a full and fair review of your case). Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 246 Upon your receipt of the First Level Appeal decision notice upholding the prior denial — if you still feel you are entitled to the denied/withheld benefit — you must file a Second Level Appeal with the PBAC. If you receive an adverse benefit determination on the First Level Appeal, you must ask for a Second Level Appeal review from the Pension Benefits Administration Committee (“PBAC”) at American Airlines, Inc. You or your authorized representative has 180 days following the receipt of a notification of an adverse benefit determination on the First Level Appeal within which to file a Second Level Appeal. If you do not file your Second Level Appeal (with the PBAC) within this time frame, you waive your right to file the Second Level Appeal of the determination. To file a Second Level Appeal with the PBAC, please complete an Application for Second Level Appeal and include with the Application all comments, documents, records and other information — including a copy of the First Level Appeal decision notice — relating to the denied/withheld benefit. (The Application for Second Level Appeal provides information about what to include with your appeal.) The PBAC will review your Second Level Appeal and will communicate its Second Level Appeal decision to you in writing: • For pre-service claims, within the 30-day time period allotted for completion of both levels of appeal • For post-service claims, within the 60-day time period allotted for completion of both levels of appeal • For urgent care claims, within the 72-hour time period allotted for completion of both levels of appeal. Example: A participant appeals an adverse benefit determination (post-service claim). For both levels of appeal – First and Second Levels, the combined time taken by the claims processor or benefit administrator and the PBAC to review and complete the appeals must be no more than 60 days. If the First Level Appeal review is completed by the claims processor or benefit administrator in 15 days, then the PBAC has the remaining 45 days (for a total of 60 days) to complete its review and render its decision. Upon its receipt your Second Level Appeal will be reviewed in accordance with the terms and provisions of the Plans and the guidelines of the PBAC. Appointed officers of American Airlines, Inc. are on the PBAC. In some cases, the PBAC designates another official to determine the outcome of the appeal. Your case, including evidence you submit and a report from the claims processor or benefit administrator, if appropriate, will be reviewed by the PBAC or its designee(s). The Second Level of Appeal is mandatory for all other claims, unless otherwise stated in this Guide. American Airlines, Inc. encourages all retirees to use both levels of appeal to exhaust all avenues to resolve any claim issues in the quickest manner possible. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 247 You have the right to: • Submit written comments, documents, records and other information relating to the claim for benefits • Request, free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits. For this purpose, a document, record or other information is treated as “relevant” to your claim if it: • Was relied upon in making the benefit determination • Was submitted, considered or generated in the course of making the benefit determination, regardless of whether such document, record or other information was relied upon in making the benefit determination • Demonstrates compliance with the administrative processes and safeguards required in making the benefit determination • Constitutes a statement of policy or guidance with respect to the Plan concerning the denied benefit for your diagnosis, regardless of whether such statement was relied upon in making the benefit determination • You are entitled to receive, free of charge, new or additional evidence considered, relied upon or generated by the plan or issuer in connection with your appeal; you shall be afforded a reasonable opportunity to respond to such evidence or rationale • A review that takes into account all comments, documents, records and other information submitted by you related to the claim, regardless of whether the information was submitted or considered in the initial benefit determination • A review that does not defer to the initial adverse benefit determination and that is conducted neither by the individual who made the adverse determination, nor that person’s subordinate • A review in which the named fiduciary consults with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was neither consulted in connection with the initial adverse benefit determination, nor the subordinate of any such individual. This applies only if the appeal involves an adverse benefit determination based in whole or in part on a medical judgment (including whether a particular treatment, drug or other item is experimental) • The identification of medical or vocational experts whose advice was obtained in connection with the adverse benefit determination, regardless of whether the advice was relied upon in making the decision • In the case of a claim for urgent care, an expedited review process in which: o You may submit a request (orally or in writing) for an expedited appeal of an adverse benefit determination o All necessary information, including the Plan’s benefit determination on review, will be transmitted between the Plan and you by telephone, facsimile or other available similarly prompt method. You must use and exhaust Plans’ administrative claims and appeals procedure before bringing a suit in federal court. Similarly, failure to follow the Plans’ prescribed procedures in a timely manner will also cause you to lose your right to sue under ERISA 502(a) regarding an adverse benefit determination. If you have exhausted your administrative claim and appeal procedures, you may only bring suit in a federal district court if you file your action or suit within two years of the date after the adverse benefit determination is made on final appeal. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 248 Compliance with Privacy Regulations Notice of Privacy Rights (Health Care Records) 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. This notice applies to all active and retired Plan participants of participating AMR Corporation subsidiaries. This Notice is effective as of February 17, 2010, and applies to health information received about you by the health care components of the Group Life and Health Benefits Plan for Employees of Participating AMR Corporation Subsidiaries (particularly, the Standard Medical Options, the Value Option, the Out-of-Area Option, the Value Plus Option, the Core Option, the HMOs, Dental Benefits, Vision Insurance Benefits, Health Care Flexible Spending Accounts Benefit, Limited Purpose Health Care Flexible Spending Account, Health Savings Account), the Supplemental Medical Plan for Employees of Participating AMR Corporation Subsidiaries, TransWorld Airlines Retiree Health and Life Benefits Plan and any other group health plan for which American Airlines, Inc. (“American”) serves as Plan Administrator (collectively, the “Plan”). You may receive notices about your medical information and how it is handled by other plans or insurers. The Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”) mandated the issuance of regulations to protect the privacy of individually identifiable health information, which were issued at 45 CFR Parts 160 through 164 (the “Privacy Regulations”) and as amended by the Genetic Information Nondiscrimination Act (“GINA”) and the American Recovery and Reinvestment Act (“ARRA”)As a participant or beneficiary of the Plan, you are entitled to receive a notice of the Plan’s privacy procedures with respect to your health information that is created or received by the Plan (your “Protected Health Information” or “PHI”). This notice is intended to inform you about how the Plan will use or disclose your PHI, your privacy rights with respect to the PHI, the Plan’s duties with respect to your PHI, your right to file a complaint with the Plan or with the Secretary of HHS and the office to contact for about the Plan’s privacy practices. The following uses and disclosures of your PHI may be made by the Plan: For Payment. Your PHI may be used or disclosed to obtain payment, including disclosures for coordination of benefits paid with other plans and medical payment coverages, disclosures for subrogation in order for the Plan to pursue recovery of benefits paid from parties who caused or contributed to the injury or illness, disclosures to determine if the claims for benefits are covered under the Plan and disclosures to obtain reimbursement under insurance, reinsurance or stop-loss policies providing reimbursement for the benefits paid under the Plan on your behalf. Your PHI may be disclosed to other health plans maintained by AMR Corporation and its subsidiaries for any of the purposes described above. ARRA requires disclosures for purposes of payment to meet its minimally necessary standard. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 249 For Treatment. Your PHI may be used or disclosed by the Plan for purposes of treating you (for example, if your doctor requests information on what other drugs you are currently receiving). For the Plan’s Operations. Your PHI may be used as part of the Plan’s health care operations. Health care operations would include quality assurance, underwriting and premium rating to obtain renewal coverage or securing or placing a contract for reinsurance of risk, including stop-loss insurance, reviewing the competence and qualification of health care providers and conducting cost management and customer service and resolution of internal grievances. ARRA requires disclosures for purposes of the Plan’s operations to meet its minimally necessary standard. The Plan is prohibited from disclosing any of your PHI that constitutes genetic information (as defined by GINA) for underwriting purposes. When Required by Law. The Plan may also be required to disclose or use your PHI for certain other purposes (for example, if certain types of wounds occur that require reporting or a disclosure to comply with a court order, a warrant, a subpoena, a summons or a grand jury subpoena). For Workers’ Compensation. The Plan may disclose your PHI as authorized by you or your representative and to the extent necessary to comply with laws relating to Workers’ Compensation and similar programs providing benefits for work-related injuries or illnesses if either, (1) the health care provider is a member of the employer’s workforce and provides health care to the individual at the request of the employer, the PHI is provided to determine if the individual has a work-related illness or injury or to provide medical surveillance of the workplace and the information is required for the employer to comply with OSHA or with laws with similar purposes, or (2) you authorize the disclosure. You must authorize the disclosure in writing and you will receive a copy of any authorization you sign. Pursuant to Your Authorization. Any other use or disclosure of your PHI will be made only with your written authorization and you may revoke that authorization in writing, except your revocation cannot be effective to the extent the Plan has taken any action relying on your authorization for disclosure. The revocation of your authorization may not be revoked if your authorization was obtained as a condition for obtaining insurance coverage and any law provides the insurer with the right to contest a claim under the policy or the policy itself. For Appointment Reminders and Health Plan Operations. Your PHI may be used so that the Plan, or one of its contracted service providers, may contact you to provide appointment reminders, information on treatment alternatives, or other health-related benefits and services that may be of interest to you, such as case management, disease management, wellness programs or retiree assistance programs. To the Plan Sponsor. Information may be provided to the Sponsor of the Plan, provided that the Sponsor has certified that this information will not be used for any other benefits, retiree benefit plans or employment-related activities. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 250 Other Uses or Disclosures of Protected Health Information Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use or release Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if: • the information is directly relevant to the family’s or friend’s involvement with your care or payment for that care and • you have either agreed to the disclosure or have been given an opportunity to object and have not objected. Uses and disclosures for which authorization or opportunity to object is not required Use and disclosure of your PHI is allowed without your authorization or any opportunity to agree or object under the following circumstances: • When required by law. • When permitted for purposes of public health activities, including when necessary to report product defects, to permit product recalls and to conduct post-marketing surveillance. PHI may also be used or disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if authorized or required by law. • When authorized or required by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In such case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made. • Disclosure may generally be made to the minor’s parents or other representatives, although there may be circumstances under federal or state law when the parents or other representatives may not be given access to a minor’s PHI. • The Plan may disclose your PHI to a public health oversight agency for oversight activities authorized or required by law. This includes uses or disclosures in civil, administrative or criminal investigations; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud). • The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request provided certain conditions are met. One of those conditions is that satisfactory assurances must be given to the Plan that the requesting party has made a good faith attempt to provide written notice to you and the notice provided sufficient information about the proceeding to permit you to raise an objection and no objections were raised or any raised were resolved in favor of disclosure by the court or tribunal. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 251 • For law enforcement purposes, including for the purpose of identifying or locating a suspect, fugitive, material witness or missing person or to report certain types of wounds. Disclosures for law enforcement purposes include disclosing information about an individual who is or is suspected to be a victim of a crime, but only if the individual agrees to the disclosure, or the Plan is unable to obtain the individual’s agreement because of emergency circumstances. • When required to be given to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized or required by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent. • The Plan may use or disclose PHI for research, subject to certain conditions. • When consistent with applicable law and standards of ethical conduct, if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat. Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to your right to revoke such authorization. State laws may provide you with additional rights or protections. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 252 Rights You May Exercise To Request Restrictions on Disclosures and Uses. You have the right to request restrictions on certain uses and disclosures of your PHI in writing. The Plan is required to comply with your request not to disclose to another plan any PHI related to any claim for which you paid in full. However, the Plan is not required to agree to any restriction you may request. You or your personal representative will be required to complete a form to request restrictions on uses and disclosures of your PHI. Such requests should be made to the following officer: Managing Director, Human Resources Delivery. To Access. You have the right to request access to your PHI and to inspect and copy your PHI in the designated record set under the policies and procedures established by the Plan. The designated record set is the series of codes that make up each electronic claim. This does not include psychotherapy notes and any information compiled in reasonable anticipation of or for the use of civil, criminal or administrative actions or proceedings or PHI that is maintained by a covered entity that is a clinical laboratory. The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained offsite. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. To the extent that the Plan uses or maintains an electronic health record, you have a right to obtain a copy of your PHI from the Plan in an electronic format. You may also direct the Plan to transmit a copy of your PHI in such electronic format directly to an entity or person designated by you. You or your personal representative will be required to complete a form to request access to the PHI in your designated record set. Requests for access to PHI should be made to the following officer: Managing Director, Human Resources Delivery at American Airlines Mail Drop 5144-HDQ1 P.O. Box 619616 DFW Airport, TX 75261-9616. If access is denied, you or your personal representative will be provided with a written denial setting forth the basis for the denial, a description of how you may exercise those review rights and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services. To Amend. You have the right to request an amendment to your PHI in writing under the policies established by the Plan. The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI. Requests for amendment of PHI in a designated record set should be made to the following officer: Managing Director, Human Resources Delivery at American Airlines, Mail Drop 5144-HDQ1, P.O. Box 619616, DFW Airport, TX 75261-9616. You or your personal representative will be required to complete a written form to request amendment of the PHI in your designated record set. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 253 To Receive an Accounting. You have the right to receive an accounting of any disclosures of your PHI, other than those for payment, treatment and health care operations. At your request, the Plan will also provide you with an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting need not include PHI disclosures made: (1) to carry out treatment, payment or health care operations (such disclosures occurring after January 1, 2014, will be required to be included in the accounting); (2) to individuals about their own PHI; (3) pursuant to a valid authorization; (4) incident to a use or disclosure otherwise permitted or required under the Privacy Regulations; (5) as part of a limited data set; or (6) prior to the date the Privacy Regulations were effective for the Plan on April 14, 2003. If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided. If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting. To Obtain a Paper Copy of This Notice. An individual who receives an electronic Notice of Privacy Practices has the right to obtain a paper copy of the Notice of Privacy Practices from the Plan upon request. To obtain a paper copy of this Notice, contact the Plan’s Privacy Officer by calling the Managing Director, Human Resources Delivery or by writing to American Airlines, Mail Drop 5144-HDQ1, P.O. Box 619616, DFW Airport, TX 75261-9616. To Request Confidential Communication. You have the right to request to receive confidential communications of your PHI. This may be provided to you by alternative means or at alternative locations if you clearly state that the disclosure of all or part of the information could endanger you. The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations. Such requests should be made to the following officer: Managing Director, Human Resources Delivery, American Airlines, Mail Drop 5144-HDQ1, P.O. Box 619616, DFW Airport, TX 75261-9616. A Note About Personal Representatives You may exercise your rights through a personal representative (e.g., having your spouse call for you). Your personal representative will be required to produce evidence of his or her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms: • a power of attorney for health care purposes, notarized by a notary public, • a signed authorization completed by you, • a court order of appointment of the person as the conservator or guardian of the individual, or • an individual who is the parent of a minor child. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 254 The Plan retains discretion to deny access to your PHI to a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect. This also applies to personal representatives of minors. The Plan is required to abide by the terms of the notice that is currently in effect. The Plan reserves the right to make amendments or changes to any and all of its privacy policies and practices described in this notice and to apply such changes to all PHI the Plan maintains. Any PHI that the Plan previously received or created will be subject to such revised policies and practices and the Plan may make the changes applicable to all PHI it receives or maintains. Any revised version of this notice will be distributed within 60 days of the effective date of any material change to the uses or disclosures, the individual’s rights, the duties of the Plan or other privacy practices stated in this notice. Minimum Necessary Standard When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request. However, the minimum necessary standard will not apply in the following situations: (1) disclosures to or requests by a health care provider for treatment; (2) uses or disclosures made to the individual; (3) disclosures made to the Secretary of the U.S. Department of Health and Human Services; (4) uses or disclosures made pursuant to an authorization you signed; (5) uses or disclosures in the designated record set; (6) uses or disclosures that are required by law; (7) uses or disclosures that are required for the Plan’s compliance with legal regulations; and (8) uses and disclosures made pursuant to a valid authorization. This notice does not apply to information that has been de-identified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. The Plan may use or disclose “summary health information” or a limited data set on and after February 17, 2010 to the plan sponsor for obtaining premium bids or modifying, amending or terminating the group health plan, which summarizes the claims history, claims expenses or type of claims experienced by individuals for whom a plan sponsor has provided health benefits under a group health plan; and from which identifying information has been deleted in accordance with HIPAA. The Plan may use or disclose a “Limited Data Set” that may be used by the Plan provided the Plan enters into a Limited Data Set agreement with the recipient of the Limited Data Set. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 255 You have the right to file a complaint with the Plan or to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may file a complaint with the Plan by filing a written notice with the Privacy Complaint Official, Chair, HIPAA Compliance Subcommittee, c/o PBAC Appeals Group, at American Airlines, Mail Drop 5134- HDQ, P.O. Box 619616, DFW Airport, TX 75261-9616, describing when you believe the violation occurred and what you believe the violation was. You will not be retaliated against for filing a complaint. You may also file a complaint with the appropriate regional office of the Office for Civil Rights of the U.S. Department of Health and Human Services, within 180 days of any alleged violation. You may obtain the address of the appropriate regional office of the Office for Civil Rights from the Privacy Complaint Official. If you would like to receive you should contact the Privacy Official, the Managing Director, Human Resources Delivery at American Airlines, Mail Drop 5144-HDQ1, P.O. Box 619616, DFW Airport, TX 75261-9616 or the Privacy Complaint Official, Chair, HIPAA Compliance Subcommittee, c/o PBAC Appeals Group, at American Airlines, Mail Drop 5134-HDQ1, P.O. Box 619616, DFW Airport, TX 75261-9616. This notice will first be in effect on February 17, 2010. and shall remain in effect until you are notified of any changes, modifications or amendments. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 256 How AMR Corporation and Its Subsidiaries, Including American Airlines, May Use Your Health Information American Airlines, Inc. (“American”), administers many aspects of the American Group Health Plans (the “Plans”), which are listed below, on behalf of AMR Corporation and its Subsidiaries, including American Airlines and American Eagle. American, as the plan sponsor and/or plan administrator of the Plans may use and disclose your personal medical information (called “Protected Health Information”) created and/or maintained by the Plans that it receives from the Plans as permitted and/or required by, and consistent with the Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Regulations found at 45 CFR Part 164, Subpart A. This includes, but is not limited to, the right to use and disclose a participant’s PHI in connection with payment, treatment and health care operations. The American Airlines Group Health Plans include the health plan components of: • The Group Life and Health Benefits Plan for Employees of Participating AMR Corporation Subsidiaries (Plan 515), • The Supplemental Medical Plan for Employees of Participating AMR Corporation Subsidiaries (Plan 503) • The Group Life and Health Benefits Plan for Retirees of Participating AMR Corporation Subsidiaries (Plan 515) • TransWorld Airlines, Inc. Retiree Health and Life Benefits Plan • Any other Group Health Plan for which American serves as Plan Administrator. This Applies To The information in this section applies only to health-related benefit plans that provide “medical care,” which means the diagnosis, cure, mitigation, treatment or prevention of disease or amounts paid for the purpose of affecting any structure or function of the body, transportation primarily for and essential to medical care and insurance covering medical care. This means that, for the Plans listed above, only the health-related benefits, including medical, prescription drug and mental health, are subject to the limitations described in this section. The EAP is included only to the extent that it is involved in the administration of medical benefits. This Section Does Not Apply To By law, the HIPAA Privacy rules and the information in this section, do not apply to the following benefit plans: • Life insurance plans • Workers’ compensation plans, which provide benefits for employment-related accidents and injuries • Property and casualty insurance. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 257 In addition, AMR Corporation and its subsidiaries may have personal medical information about you that is used for routine employment activities. Medical information held or used by AMR Corporation and its subsidiaries in its employment records for employment purposes is not subject to the HIPAA Privacy rules. This includes, but is not limited to, medical information, files or records related to compliance with government occupational and safety requirements, the Americans with Disabilities Act (ADA) or other employment law requirements, occupational injury, disability insurance eligibility, sick leave requests or justifications, drug or alcohol screening results, workplace medical surveillance, fitness-for-duty test results or other medical information needed to meet Federal Aviation Administration (FAA), Department of Transportation (DOT) or other company policy or government requirements. Information used by the EAP in its role in administering employment-related programs, such as drug and alcohol testing, is not subject to the HIPAA Privacy rules. The Plans will disclose PHI to the employer Plan Sponsor (American Airlines or other current or former AMR subsidiary) only upon receipt of a certification by the employer that the plan documents have been amended to incorporate all the required provisions as described below. To the extent that PHI is maintained by one of the Plans, American and all other participating current or former subsidiaries of AMR Corporation for which American administers the Plans have agreed to: • Not use or further disclose the information other than as permitted or required by this • Employee or Retiree Benefits Guide, as it may be amended by American from time-to-time or as required by law • Ensure that any agents, including a subcontractor, to whom the Plans give PHI, agree to the same restrictions and conditions that apply to the employer Plan Sponsor with respect to such information • Not use or disclose PHI for employment-related actions and decisions or in connection with any other benefit or retiree benefit plan of the employer Plan Sponsor, unless that use or disclosure is permitted or required by law (for example, for Workers’ Compensation programs) or unless such other benefit is part of an organized health care arrangement with the plan • To the extent that the employer Plan Sponsor becomes aware that there is any use or disclosure of PHI that is inconsistent with the permitted uses or disclosures, to report such improper uses or disclosures to the Plan • Make available PHI in accordance with individual rights to review their PHI • Make available PHI for amendment and consider incorporating any amendments to PHI consistent with the HIPAA rules • Upon request and to the extent mandated by applicable law, make available the information required to provide an accounting of disclosures in accordance with the HIPAA rules • Use appropriate safeguards to prevent use or disclosure of the PHI other than as provided for by this Plan Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 258 • Agree to the same restrictions and conditions that apply to the Plan with respect to such information and enter into Business Associate agreements that comply with the standards for such agreements in the Privacy Regulations • Enter into limited data set use agreements when the Plan discloses data de- identified in compliance with the requirements for a limited data set as provided in the Privacy Regulations pursuant to a Limited Data Set use or disclosure agreement that meets the standards of the Privacy Regulations • Terminate any Business Associate agreement or Limited Data Set agreement in the event the Plan becomes aware of a pattern of non-compliance with the terms of the agreement • Provide the individual who is the subject of the PHI with the opportunity to request restrictions on the PHI’s disclosure in accordance with the Plan’s policy on requesting restrictions on disclosure of PHI • Provide the individual who is the subject of the PHI with the opportunity to request confidential communication of PHI from the Plan to the individual in accordance with the Plan’s policies and procedures • Incorporate any amendments or corrections to PHI when such amendment is determined to be required by the Plan’s policy on amendment of PHI • Make its internal practices, books and records relating to the use and disclosure of PHI received from the Plans available to the Secretary of the Department of Health and Human Services for purposes of determining compliance by the Plans • If feasible, return or destroy all PHI received from the Plans that the employer Plan Sponsor still maintains in any form. The employer Plan Sponsor will retain no copies of PHI when no longer needed for the purpose for which disclosure was made. An exception may apply if the return or destruction is not feasible, but the Plans must limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible, and • Ensure that there is an adequate separation between the Plans and the employer Plan Sponsor as will be set forth below. Forms & guides can be located in the eHR Center of Jetnet at https://www.jetnet.aa.com/jetnet/go/ssoehr.asp?TargetDoc=XML=20 The Benefits Service Center is available at https://www.jetnet.aa.com/jetnet/go/ssomercer.asp 259 Separation of AMR Corporation and Its Subsidiaries, Including American Airlines and the Group Health Plans The following employees or classes of employees or other persons under the control of American Airlines or another AMR subsidiary shall be given access to PHI for the purposes related to the Plan: • Health Strategy employees involved in health plan design, vendor selection and administration of the Plans and including the Plan Managers and administrative assistants, secretarial and support staff; as well as any Retirement Strategy employees involved in health plan issues • Pension Benefits Administration Committee (PBAC), its delegated authority and PBAC Advisory Committee members, due to their role in governing health plan matters, including reviewing and approving plan design changes, rendering appeal decisions and other health plan administrative matters • Benefits Compliance and the PBAC Appeals group personnel involved in receiving, researching and responding to health plan member appeals filed with the PBAC • Employee Services personnel and HR Services personnel who assist with day- to-day health plan operations, including Vendor Relations personnel; Retirement Counselors, who assist with retiree medical coverage questions; employees involved in receiving, reviewing and processing Qualified Medical Child Support Orders; and all call center personnel, case coordinators and support staff who assist employees and retirees by answering questions, researching issues and resolving health plan problems, including those administering the Travel program; Leave of Absence coordinators working with health plan enrollment issues; Survivor Support counselors, who assist with health plan issues for survivors; and administrative assistants, secretarial and support staff for the employees listed • Instructors who train Employee Services and HR Services personnel and thus have access to the call center systems • HR Records Room personnel responsible for managing benefit plan record