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Effective: January 1, 2009
This Notice
applies to you if you participate in any of the following Prescription Drug
Plans:
- Educators Rx Basic
- Educators Rx Advantage
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.
Section 1. Introduction
Educators Mutual Insurance
Association (“Prescription Drug Plan”) is dedicated to maintaining the privacy
of your health information. This Notice governs benefits that the Prescription
Drug Plan provides to you through the purchase of insurance from Educators
Mutual Insurance Association.
The Prescription Drug Plan is required
by law to take reasonable steps to ensure the privacy of your personally
identifiable health information or “Protected Health Information” (“PHI”) and
to inform you about:
·
how the Prescription Drug Plan uses and
discloses your PHI;
·
your privacy rights with respect to your PHI;
·
the Prescription Drug Plan’s legal duties with
respect to your PHI;
·
your right to file a complaint with the Prescription
Drug Plan and/or with the Secretary of the U.S. Department of Health and Human
Services; and
·
the person or
office to contact for further information about the Prescription Drug Plan’s
privacy practices.
The
term “Protected Health Information” or “PHI” means all individually
identifiable health information transmitted or maintained by the Prescription
Drug Plan, regardless of form (oral, written, electronic).
The
Prescription Drug Plan is required by law to maintain the privacy of PHI and to
provide individuals with notice of its legal duties and privacy practices.
The
Prescription Drug Plan is required to comply with the terms of this Notice.
However, the Prescription Drug Plan reserves the right to change its privacy
practices and to apply the changes to all PHI received or maintained by the Prescription
Drug Plan, including PHI received or maintained prior to the change. If a
privacy practice described in this Notice is changed, a revised version of this
Notice will be provided to all individuals then covered under the Prescription
Drug Plan for whom the Plans still maintain PHI. The revised notice will be posted
on the Prescription Drug Plan’s website at www.educatorsmutual.com.
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 rights, the duties of the Prescription Drug Plan or the other
privacy practices described in this Notice.
Section 2. Notice of PHI Uses
and Disclosures
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. Please note that Utah Law may impose additional restrictions on
how the Prescription Drug Plan may use and disclose health information that
relates to HIV/AIDS, domestic violence/abuse and substance abuse and chemical
dependency beyond those described below.
A. Required PHI Uses and Disclosures
Upon
your request, the Prescription Drug Plan is required to give you access to
certain PHI in order to inspect and copy it.
Use
and disclosure of your PHI may be required by the Secretary of the Department
of Health and Human Services to investigate or determine the Prescription Drug
Plan's compliance with the privacy regulations.
The
Prescription Drug Plan may contract with business associates for certain
services related to the Prescription Drug Plan. PHI about you may be disclosed
to these business associates so that they can perform contracted services. To
protect your PHI, each business associate is required to appropriately
safeguard your PHI.
The
following categories describe the different ways in which the Prescription Drug
Plan (and its business associates, as applicable) may use and disclose your
PHI.
B.
Uses and disclosures to carry out treatment, payment and health care
operations
The
Prescription Drug Plan may use PHI without your consent, authorization, or
opportunity to agree or object, to carry out treatment, payment and health care
operations.
Treatment is the provision, coordination or management of
health care and related services. It also includes but is not limited to
consultations and referrals between one or more of your providers.
For
example, the Prescription Drug Plan may disclose to a treating specialist the
name of your physician so that the specialist may ask for your lab results from
the primary care physician.
Payment includes but is not limited to actions to make
coverage determinations and payment (including billing, claims management,
subrogation, plan reimbursement, reviews for medical necessity and
appropriateness of care and utilization review and preauthorizations).
For
example, the Prescription Drug Plan may inform a physician whether you are
eligible for coverage or what percentage of the bill will be paid by the Prescription
Drug Plan.
Health care operations include but are not limited to quality assessment
and improvement, reviewing competence or qualifications of health care
professionals, underwriting, premium rating and other insurance activities
relating to creating or renewing insurance contracts. It also includes disease
management, case management, conducting or arranging for medical review, legal
services and auditing functions including fraud and abuse compliance programs,
business planning and development, business management and general
administrative activities.
For
example, the Prescription Drug Plan may use information about your claims to
refer you to a disease management program, project future benefit costs or
audit the accuracy of its claims processing functions.
The Prescription Drug Plan may
also use PHI to contact you to provide appointment reminders or information
about treatment alternatives or other health-related benefits and services that
may be of interest to you.
C.
Authorized uses and disclosures
You
must provide the Prescription Drug Plan with your written authorization for the
types of uses and disclosures that are not identified by this Notice or
permitted or required by applicable law.
Any
authorization you provide to the Prescription Drug Plan regarding the use and
disclosure of your health information may be revoked at any time in
writing. After you revoke your
authorization, the Prescription Drug Plan will no longer use or disclose your
health information for the reasons described in the authorization, except for
the two situations noted below:
·
The Prescription
Drug Plan has taken action in reliance on your authorization before it received
your written revocation; or
·
You were
required to give the Prescription Drug Plan your authorization as a condition
of obtaining coverage.
D.
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 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.
E.
Uses and disclosures for which consent, authorization or opportunity to
object is not required
Use
and disclosure of your PHI is allowed without your consent, authorization or
request 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 by law. PHI may also
be disclosed to a public health authority authorized to receive reports of
child abuse, under certain circumstances.
• When authorized 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 Prescription Drug 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.
• To a public health oversight agency for
oversight activities authorized 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).
• 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.
• For law enforcement purposes, including to
report certain types of wounds or for the purpose of identifying or locating a
suspect, fugitive, material witness or missing person, provided certain
requirements are met. The Prescription Drug Plan may also disclose PHI about an
individual who is or is suspected to be a victim of a crime, under certain
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 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.
• For research, subject to certain
conditions.
• When consistent with applicable law and
standards of ethical conduct if the Prescription Drug 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.
• When
authorized by and to the extent necessary to comply with workers’ compensation
or other similar programs established by law.
Section
3. Rights of Individuals
A. Right to Request Restrictions on
PHI Uses and Disclosures
You
may request that the Prescription Drug Plan restrict uses and disclosures of
your PHI to carry out treatment, payment or health care operations, or restrict
uses and disclosures to family members, relatives, friends or other persons
identified by you who are involved in your care or payment for your care.
However, the Prescription Drug Plan is not required to agree to your request.
You
or your personal representative will be required to complete a form to request
restrictions on uses and disclosures of your PHI.
If
you wish to make a request to restrict uses and disclosures of your PHI, you
should make your request at the address listed at the end of this Notice.
B.
Right to Request Communications by Alternative Means/Locations
The
Prescription Drug Plan will accommodate reasonable requests to receive
communications of PHI by alternative means or at alternative locations if you
state that the disclosure of all or part of your PHI could endanger you.
You
or your personal representative will be required to complete a form to request
alternative communications.
If
you wish to make a request for communications by alternative means, you should
make your request to the address listed at the end of this Notice.
C.
Right to Inspect and Copy PHI
You
have a right to inspect and obtain a copy of your PHI contained in a
“designated record set” for as long as the Prescription Drug Plan maintains the
PHI.
“Designated Record Set” includes enrollment, payment, billing, claims
adjudication and case or medical management record systems maintained by or for
a health plan, or other information used by the Prescription Drug Plan to make
decisions about individuals.
You
or your personal representative will be required to complete a form to request
access to the PHI in your designated record set.
If
you wish to make a request for access, you should make your request to the
address listed at the end of this Notice.
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.
If the Prescription Drug Plan is unable to meet this timeline, it may exercise
a single 30-day extension under certain circumstances.
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 review rights, if any, and a description of how you may complain
to the Secretary of the U.S. Department of Health and Human Services.
D. Right to Amend PHI
You
have the right to request the Prescription Drug Plan amend your PHI or a record
about you in a designated record set for as long as the PHI is maintained in
the designated record set. You or your personal representative will be required
to complete a form to request amendment of the PHI in your designated record
set.
If
you wish to make a request to amend PHI, you should make your request to the
address listed at the end of this Notice.
The
Prescription Drug Plan has 60 days after the request is made to act on the request.
A single 30-day extension is permitted if the Prescription Drug Plan is unable
to comply with the deadline. If your request is denied in whole or part, the Prescription
Drug Plan must provide you with a written explanation of 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.
E. Right to Receive an
Accounting of PHI Disclosures
At
your request, the Prescription Drug Plan will also provide you with an
accounting of disclosures by the Prescription Drug 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; (2) to you about your own PHI; (3) prior to April 14, 2003; or
(4) pursuant to your authorization.
If
you request more than one accounting within a 12-month period, the Plan may
charge a reasonable, cost-based health fee for each subsequent accounting.
You
or your personal representative will be required to complete a form to request
an accounting.
If
you wish to make a request for an accounting, you should make your request to
the address listed below at the end of this Notice.
If
the Prescription Drug Plan cannot provide you with an accounting within 60
days, a single 30-day extension is permitted, provided the Prescription Drug Plan
gives you a written statement of the reasons for the delay and the date by
which the accounting will be provided.
F. The Right to Receive a Paper Copy
of This Notice Upon Request
To
obtain a paper copy of this Notice contact:
Privacy Officer
Educators Mutual
Insurance Association
852 East Arrowhead Lane
Murray, Utah 84107-5298
Telephone: Salt Lake City (801) 262-7476
Outside Salt Lake City (800) 662-5850
Outside
Utah (800)
548-5264
G. A
Note About Personal Representatives
You may exercise your rights
through a personal representative. Your personal representative will be
required to produce evidence of his/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 court order of appointment of the person as the conservator or guardian of the individual; or
- proof that the individual is the parent of a minor child
The Prescription Drug 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.
Section 4. Your Right to File a Complaint With the Plans or the HHS Secretary
If you believe that your privacy rights have been violated, you may complain to the Prescription Drug Plan in care of:
Privacy Officer
Educators Mutual Insurance Association
852 E. Arrowhead Lane
Murray, Utah 84107
Telephone:
Salt Lake City (801) 262-7476
Outside Salt Lake City (800) 662-5850
Outside Utah (800) 548-5264
You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue S.W.,Washington, D.C. 20201.
The Prescription Drug Plan will not retaliate against you for filing a complaint.
Section 5. Whom to Contact at the Plans for More Information
If you have any questions regarding this Notice or the subjects addressed in it, you may contact:
Privacy Officer
Educators Mutual Insurance Association
852 E. Arrowhead Lane
Murray, Utah 84107
Telephone: Salt Lake City (801) 262-7476
Outside Salt Lake City (800) 662-5850
Outside Utah (800) 548-5264
Section 6. Conclusion
PHI use and disclosure by the Plans is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations.
Section 7. Contact Information
If you wish to exercise one or more of the rights listed in this Notice, contact the representative listed below:
Privacy Officer
Educators Mutual Insurance Association
852 East Arrowhead Lane
Murray, Utah 84107-5298
Telephone: Salt Lake City (801) 262-7476
Outside Salt Lake City (800) 662-5850
Outside Utah (800) 548-5264
Educators Mutual Insurance Association is a Medicare Contractor for Utah and Idaho.
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