EDUCATORS
HEALTH CARE
EDUCATORS
HEALTH PLANS HEALTH
Effective: March 28, 2006
If
you participate in any of the following benefits:
-
Medical
Benefits
-
Dental
Benefits
-
Vision
Benefits
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 of Utah and its affiliates listed above (“Health Plan”) are
dedicated to maintaining the privacy of your health information. This Notice
governs certain health insurance benefits that you may purchase from us
(i.e., Medical, Dental, and Vision benefits).
The Health Plan is required
by law to maintain the privacy of your personally identifiable health
information or “Protected Health Information” (“PHI”) and to inform you
about:
· how it uses and discloses your PHI;
· your privacy rights with respect to your PHI;
· the Health Plan’s duties with respect to your PHI;
· your right to file a complaint with the Health Plan 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 Health Plan’s privacy practices.
The
term “Protected Health Information” or “PHI” means all individually identifiable
health information transmitted or maintained by the Health Plan, regardless of
form (oral, written, electronic).
The Health Plan is
required to comply with the terms of this Notice. However, the Health Plan
reserves the right to change its privacy practices and to apply the changes to
all PHI received or maintained by the Health 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 Health Plan for whom the Plan still maintains PHI. The
revised notice will be posted on the Health Plan’s website at
www.educatorsmutual.com and will be sent to you via
e-mail.
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 Health 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 Health Plan may use and/or disclose specific
types of health information (e.g., health information that relates to
HIV/AIDS, domestic violence/abuse and substance abuse and chemical dependency)
beyond those described below. In other words, we may further restrict the uses
and disclosures described herein for the types of information listed above,
where required by state law in Utah.
Upon your request, the Health 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 Health Plan's compliance with the
privacy regulations.
The Health Plan may
contract with business associates for certain services related to the Health
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 Health 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 Health Plan may use
and disclose your PHI 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 Health
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 Health
Plan may inform a physician whether you are eligible for coverage or what
percentage of the bill will be paid by the Health 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 Health
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 Health 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
Health 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. In addition, your
written authorization generally will be obtained before the Health Plan will use
or disclose psychotherapy notes about you from your mental health professional.
Psychotherapy notes are separately filed notes about your conversations with
your mental health professional during a counseling session. They do not include
summary information about your mental health treatment. The Health Plan may use
and disclose such notes when needed by the Health Plan to defend against a legal
action or other proceeding filed by you, and in other limited instances, without
your written authorization.
Any authorization you
provide to the Health Plan regarding the use and disclosure of your health
information may be revoked at any time in writing. After you revoke your authorization, the
Health Plan will no longer use or disclose your PHI for the reasons described in
the authorization, except for the two situations noted
below:
·
The Health
Plan has taken action in reliance on your authorization before it received your
written revocation; or
·
You were
required to give the Health 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 Health 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 Health 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 Health
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.
A. Right to Request Restrictions on PHI Uses and
Disclosures
You may request that the
Health 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 Health 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 Health 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.
You have a right to
inspect and obtain a copy of your PHI contained in a “designated record set” for
as long as the Health 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 Health 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 Health 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.
You have the right to request the Health 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 Health Plan has 60
days after the request is made to act on the request. A single 30-day extension
is permitted if the Health Plan is unable to comply with the deadline. If your
request is denied in whole or part, the Health 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
Health Plan will also provide you with an accounting of disclosures by the
Health 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 Health Plan cannot provide you with an accounting within 60 days, a single 30-day extension is permitted, provided the health 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 of
Utah
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
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 Health 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 Health Plan in care of:
Privacy Officer
Educators Mutual Insurance Association of
Utah
852 E. Arrowhead Lane
Murray, Utah
84107
You may also file a
complaint with the Secretary of the U.S. Department of Health and Human
Services.
The Health Plan will not
retaliate against you for filing a complaint.
Section 5. Whom to Contact at the Plan for More
Information
If you have any questions regarding this Notice or the
subjects addressed in it, or would like to exercise one or more of your
individual rights you may contact:
Privacy
Officer
Educators Mutual Insurance Association of
Utah
852 E. Arrowhead Lane
Murray, Utah 84107
Contact: Privacy Officer
Telephone: Salt Lake City (801) 262-7476
Outside Salt Lake City
(800) 662-5850
Outside Utah (800)
548-5264
HIPAA.PRIVACY-NOTICE.COMB.0406.1804