Federally Mandated Notices

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Healthcare Reform Article

Healthcare Exchange Letter

HIPAA Privacy Notice 

Medicare Notice of Creditable Coverage

Newborns' and Mothers' Health Protection Act 

Summary of Benefits and Coverage (SBC) for City of Mesa Medical Plans

Children's Health Insurance Program (CHIP) 

Women's Health & Cancer Rights Act of 1998

COBRA Initial Notification

State of Massachusetts Creditable Coverage Letter


AFFORDABLE CARE ACT NONDISCRIMINATION STATEMENT AND GRIEVANCE PROCEDURE (Effective January 1, 2017):

City of Mesa Health Plan complies with applicable Federal civil rights laws and does not discriminate in health programs and activities on the basis of race, color, national origin, sex, age or disability. The Health Plan has adopted an internal grievance procedure providing for prompt resolution of complaints alleging discrimination on the basis of these factors. The Plan Administrator (or designee) has been designated as the Grievance Coordinator for these purposes (address and contact information described in the General Information section of the City of Mesa Health Plan Document).  Applicable grievances must be submitted in writing within sixty (60) days of awareness of the alleged discriminatory action and include the following information: name and address of person filing the grievance, problem or actions alleged to be discriminatory (including relevant evidence) and remedy or relief sought.

The Grievance Coordinator will review the complaint/submitted evidence and issue a confidential written decision no later than thirty (30) days after the grievance is received and including a notice of the right to pursue further administrative appeal with the Plan’s Employee Benefits Advisory Committee (EBAC), within fifteen (15) days of receiving the Grievance Coordinator’s decision. EBAC will meet to discuss the appeal at the next scheduled time (monthly) and issue a written decision no later than thirty (30) days after Committee review of the appeal.

The availability and use of this internal grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination, in court or with the U.S. Department of Health and Human Services, Office of Civil Rights, within one hundred and eighty (180) days of the date of the alleged discrimination, electronically at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail (complaint forms available online at http://www.hhs.gov/ocr/office/file/index.html) to:  U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509H, HHH Building, Washington, D.C 20201.

City of Mesa Health Plan will make appropriate arrangements to ensure that individuals with disabilities and/or limited English proficiency are provided services and assistance to participate in this grievance process and/or generally participate in Health Plan enrollment, claims and other benefit services. 

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