Required Legal Notices

If you or an enrolled dependent knowingly submit false information when enrolling in, changing or claiming health and insurance benefits, or if you fail to notify the Belk HR Shared Services that an enrolled dependent is no longer eligible for coverage, participation for you and your dependents may be immediately, retroactively and permanently cancelled. In addition, the insurance company may deny coverage. Pending claims may not be paid, and you must reimburse the plan for any previous claims incurred that should not have been paid. You also may be subject to disciplinary action, up to and including termination of employment.

The value of certain benefits is considered imputed income, which means that you pay taxes on the value of that coverage. (Basic life in excess of $50,000.)

If imputed income affects you, you will see it beginning on the first payroll statement you receive in 2022.

As required by the Women’s Health and Cancer Rights Act of 1998, the medical plan provides the following medical and surgical benefits with respect to a mastectomy:

• Reconstruction of the breast on which the mastectomy has been performed.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance.
• Prostheses and treatment of physical complication of all stages of the mastectomy, including lymphedema.

These services must be provided in a manner determined in consultation with the attending physician and the patient. This coverage may be subject to annual deductibles and copayment provisions applicable too other such medical and surgical benefits provided under the plan.

In 2006, prescription drug coverage became available through Medicare. All Medicare prescription drug plans provide at least a minimum standard level of coverage set by Medicare. Some plans may also offer additional coverage for a higher monthly premium.

More information about Medicare prescription drug coverage is available at www.medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227).

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS-NOW (1-877-543-7669) or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (1-866-444-3272).

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal delivery, or less than 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable).

TO: Participants in the Belk Employees’ Healthcare Plan, Belk Employees’ Vision Plan, Belk Employees’ Healthcare Flexible Spending Account, Belk Part Time Employees’ Dental Plan, and Belk Part Time Employees’ Vision Plan (collectively, the “Plan”), sponsored by Belk, Inc. (“Belk”).

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 only pertains to those benefits under the Plan which are covered under the Health Insurance Portability and Accountability Act of 1996.)

As we work every day to operate your health plan, protecting the confidentiality of your personal medical information has always been an important priority. The Plan has adopted policies to safeguard the privacy of your medical information and comply with federal law (specifically, the Health Insurance Portability and Accountability Act, known as “HIPAA”).

Note: “We” refers to the Belk Employees’ Healthcare Plan, Belk Employees’ Vision Plan, Belk Employees’ Healthcare Flexible Spending Account, Belk Part Time Employees’ Dental Plan, and Belk Part Time Employees’ Vision Plan (collectively referred to in this Notice as the “Plan”). “You” or “yours” refers to the individual participants in the Plan. If you are covered by an insured health option under the Plan, you may have or will also receive a separate notice from your insurer or HMO.

This Notice explains:

• How your personal medical information may be used, and
• What rights you have regarding this information.

How The Plan May Use Your Information

In order to manage your health plan effectively, we are permitted by law to use and disclose your personal medical information (called “Protected Health Information”) in certain ways without your authorization:

• For Treatment. So that you receive appropriate treatment and care, providers may use your Protected Health Information to coordinate or manage your health care services. The Plan may disclose your PHI to a health care provider who renders treatment on your behalf. For example, if you are unable to provide your medical history as the result of an accident, the Plan may advise an emergency room physician about the types of prescription drugs you currently take.
• For Payment. To make sure that claims are paid accurately and you receive the correct benefits, we may use and disclose your Protected Health Information to determine plan eligibility and responsibility for coverage and benefits. For example, we may use your information when we confer with other health plans to resolve a coordination of benefits issue. We may also use your Protected Health Information for utilization review activities.
• For Health Care Operations. To ensure quality and efficient plan operations, we may use your Protected Health Information in several ways, including plan administration, quality assessment and improvement, and vendor review. Your information could be used, for example, to assist in the evaluation of a vendor who supports us. We also may contact you with appointment reminders or to provide information about treatment alternatives or other health-related benefits and services available under the Plan.

We may also disclose your Protected Health Information to Belk (the plan sponsor) in connection with these activities. If you are covered under an insured health plan, the insurer also may disclose Protected Health Information to the plan sponsor in connection with payment, treatment or health care operations.

The Plan is prohibited from using or disclosing genetic information for underwriting purposes, and will not use or disclose any of your Protected Health Information which contains genetic information for underwriting purposes.

Other Permitted Uses and Disclosures

Federal regulations allow us to use and disclose your Protected Health Information, without your authorization, for several additional purposes, in accordance with law:

• Public health
• Reporting and notification of abuse, neglect or domestic violence
• Oversight activities of a health oversight agency
• Judicial and administrative proceedings
• Law enforcement
• Research, as long as certain privacy-related standards are satisfied
• To a coroner or medical examiner
• To organ, eye or tissue donation programs
• To avert a serious threat to health or safety
• Specialized government functions (e.g., military and veterans’ activities, national security and intelligence, federal protective services, medical suitability determinations, correctional institutions and other law enforcement custodial situations)
• Workers’ compensation or similar programs established by law that provide benefits for work-related injuries or illness
• Other purposes required by law, provided that the use or disclosure is limited to the relevant requirements of such law.

In Special Situations

We may disclose your Protected Health Information to a family member, relative, close personal friend, or any other person whom you identify, when that information is directly relevant to the person’s involvement with your care or payment related to your care.

We also may use your Protected Health Information to notify a family member, your personal representative, another person responsible for your care, or certain disaster relief agencies of your location, general condition, or death. If you are incapacitated, there is an emergency, or you otherwise do not have the opportunity to agree to or object to this use or disclosure, we will do what in our judgment is in your best interest regarding such disclosure and will disclose only information that is directly relevant to the person’s involvement with your health care.

Uses and Disclosures for which an Authorization is Required

Your authorization is required for most uses and disclosures of psychotherapy notes, uses and disclosures of Protected Health Information for marketing purposes, and disclosures which constitute a sale of Protected Health Information. We will make any other uses and disclosures not described in this Notice only after you authorize them in writing. You may revoke your authorization in writing at any time, except to the extent that we have already taken action in reliance on the authorization.

Your Rights Regarding Protected Health Information

You have the right to:

• Inspect and copy your Protected Health Information
• Amend or correct inaccurate information
• Receive a paper copy of this Notice, even if you agreed to receive it electronically
• Receive an accounting of certain disclosures of your information made by us
• However, you are not entitled to an accounting of several types of disclosures including, but not limited to:
• Disclosures made for payment, treatment or health care operations
• Disclosures you authorized in writing
• Disclosures made before April 14, 2003.

Right to Request Restrictions

You may ask us to restrict how we use and disclose your Protected Health Information as we carry out payment, treatment, or health care operations. You may also ask us to restrict disclosures to your family members, relatives, friends, or other persons you identify who are involved in your care or payment for your care. However, we are not required to agree to these requests.

Right to Request Confidential Communications

You may request to receive your Protected Health Information by alternative means or at an alternative location if you reasonably believe that other disclosure could pose a danger to you. For example, you may only want to have information sent by mail or to an address other than your home.

Complaints

If you believe that your privacy rights have been violated, or that the privacy or security of your unsecured Protected Health Information has been compromised, you may file a written complaint without fear of reprisal. Direct your complaint to Belk (see below) or to the appropriate regional office of the Office of Civil Rights, U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.

About This Notice

We are required by law to maintain the privacy of your Protected Health Information, to provide you with a copy of this Notice regarding our legal duties and privacy practices with respect to Protected Health Information, and to notify you following a breach of your unsecured Protected Health Information. We reserve the right to change the terms of this Notice and to make the new notice provisions effective for all Protected Health Information we maintain. If we change this Notice, you will receive a copy of the new Notice from the Plan. A copy of the current Notice will be maintained by Belk’s Benefits Department at all times.

Contacting Us

You may exercise the rights described in this Notice by contacting the Belk office identified below, which will provide you with additional information. The contact is:

Belk, Inc.
Benefits Department
ATTN: HIPAA Privacy Officer
2801 West Tyvola Road Charlotte, NC 28217
Phone: 1-800-588-3700 Option 3
Email: hrsharedservices@belk.com.

The benefits described in this Open Enrollment Guide apply to eligible full-time associates. If there is any discrepancy between the information in these materials and the plan document, the plan document will always govern. Belk may modify, suspend or terminate any plan, program, policy or guideline described on this website at any time. Belk also retains the discretion to interpret any terms or language used on this website.