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.
Health New England (HNE) knows how important it is to protect your privacy at all times and in all settings. This Notice of Privacy Practices describes how HNE may collect, use and disclose your protected health information, and your rights concerning your protected health information. “Protected health information” or “PHI” is information about you, including demographic information, that can reasonably be used to identify you and that relates to your past, present or future physical or mental health or condition, the provision of health care to you or the payment for that care.
State and federal law require us to maintain the privacy of your protected health information. The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) also requires us to provide you this notice about our legal duties and privacy practices.
This notice takes effect August 1, 2016. We must follow the privacy practices described in this Notice while it is in effect. We may change the terms of this Notice at any time in the future and make the new Notice effective for all PHI that we maintain. This Notice replaces any other information you have previously received from us with respect to your PHI. Whenever we make an important change, we will publish the updated Notice on our Web site at http://healthnewengland.org/notice-of-privacy-practices. We will inform subscribers whenever we make a material change to the privacy practices described in this notice in one of our periodic mailings.
How does HNE protect my personal health information?
HNE has a detailed policy on confidentiality. All HNE employees are required to protect the confidentiality of your PHI. An employee may only access your information when they have an appropriate reason to do so. Each employee or temporary employee must sign a statement that he or she has read and understands the policy. On an annual basis, HNE will send a notice to employees to remind them of this policy. Any employee who violates the policy is subject to discipline, up to and including dismissal. If you would like a copy of HNE’s Policy on Confidentiality, you may request a copy from HNE Member Services. In addition, HNE includes confidentiality provisions in all of its contracts with Plan Providers. HNE also maintains physical, electronic, and procedural safeguards to protect your information.
How does HNE collect protected health information?
HNE gets PHI from:
• Information we receive directly or indirectly from you, your employer or benefits plan sponsor through applications, surveys, or other forms (e.g., name, address, social security number, date of birth, marital status, dependent information, employment information and medical history).
• Providers who are treating you or who are involved in your treatment and/or their staff when they submit claims or request authorization on your behalf for certain services or procedures.
• Attorneys who are representing our Members in automobile accidents or other cases.
• Insurers and other health plans.
How does HNE use and disclose my protected health information?
HIPAA and other laws allow or require us to use or disclose your PHI for many different reasons. We can use or disclose your PHI for some reasons without your written agreement. For other reasons, we need you to agree in writing that we can use or disclose your PHI.
Uses and Disclosures for Treatment, Payment and Health Care Operations: HNE uses and discloses protected health information in a number of different ways in connection with your treatment, the payment for your health care, and our health care operations. We can also disclose your information to providers and other health plans that have a relationship with you, for their treatment, payment and some limited health care operations. The following are only a few examples of the types of uses and disclosures of your protected health information that we are permitted to make without your authorization for these purposes:
Treatment: We may disclose your protected health information to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers) who request it in connection with your treatment. We may also disclose your protected health information to health care providers (including their employees or business associates) in connection with preventive health, early detection and disease and case management programs.
Payment: We will use and disclose your protected health information to administer your health benefits policy or contract, which may involve:
• Determining your eligibility for benefits;
• Paying claims for services you receive;
• Making medical necessity determinations;
• Coordinating your care, benefits or other services;
• Coordinating your HNE coverage with that of other plans (if you have coverage through more than one plan), to make sure that the services are not paid twice;
• Responding to complaints, appeals and external review requests;
• Obtaining premiums, underwriting, ratemaking and determining cost sharing amounts; and
• Disclosing information to providers for their payment purposes.
Health Care Operations: We will use and disclose your protected health information to support HNE’s other business activities, including the following:
• Conducting quality assessment activities, or for the quality assessment activities of providers and other health plans that have a relationship with you;
• Developing clinical guidelines;
• Reviewing the competence or qualifications of providers that treat our members;
• Evaluating our providers’ performance as well as our own performance;
• Obtaining accreditation by independent organizations such as the National Committee for Quality Assurance;
• Maintaining state licenses and accreditations;
• Conducting or arranging for medical review, legal services and auditing functions including fraud and abuse detection and compliance programs;
• Business planning and development, including the development of HNE’s drug formulary;
• Operation of preventive health, early detection and disease and case management and coordination of care programs, including contacting you or your doctors to provide appointment reminders or information about treatment alternatives, therapies, health care providers, settings of care or other health-related benefits and services;
• Reinsurance activities; and
• Other general administrative activities, including data and information systems management and customer service.
Other Permitted or Required Uses and Disclosures of Protected Health Information. In addition to treatment, payment and health care operations, federal law allows or requires us to use or disclose your protected health information in the following additional situations without your authorization:
Required by Law: We may use or disclose your protected health information to the extent we are required to do so by state or federal law. For example, the HIPAA law compels us to disclose PHI when required by the Secretary of the Department of Health and Human Services to investigate our compliance efforts.
Public Health Activities: We may disclose your protected health information to an authorized public health authority for purposes of public health activities. The information may be disclosed for such reasons as controlling disease, injury or disability. We also may have to disclose your PHI to a person who may have been exposed to a communicable disease or who may otherwise be at risk of contracting or spreading the disease. In addition, we may make disclosures to a person subject to the jurisdiction of the Food and Drug Administration, for the purpose of activities related to the quality, safety or effectiveness of an FDA-regulated product or activity.
Abuse or Neglect: We may make disclosures to government authorities if we believe you have been a victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when we are required or authorized by law to do so.
Health Oversight: We may disclose your protected health information to a government agency authorized to oversee the healthcare system or government programs, or its contractors (e.g., state insurance department, U.S. Department of Labor) for activities authorized by law, such as audits, examinations, investigations, inspections and licensure activity.
Legal Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal and, in certain cases, in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose your protected health information under limited circumstances to law enforcement officials. For example, disclosures may be made in response to a warrant or subpoena or for the purpose of identifying or locating a suspect, witness or missing persons or to provide information concerning victims of crimes.
Coroners, Funeral Directors and Organ Donation: We may disclose your protected health information in certain instances to coroners, funeral directors and organizations that help find organs, eyes, and tissue to be donated or transplanted.
Threat to Health or Safety: If we believe that a serious threat exists to your health or safety, or to the health and safety of any other person or the public, we will notify those persons we believe would be able to help prevent or reduce the threat.
Military Activity and National Security: We may disclose your protected health information to Armed Forces personnel under certain circumstances and to authorized federal officials for the conduct of national security and intelligence activities.
Correctional Institutions: If you are an inmate in a correctional facility, we may disclose your protected health information to the correctional facility for certain purposes, including the provision of health care to you or the health and safety of you or others.
Workers’ Compensation: We may disclose your protected health information to the extent required by workers’ compensation laws.
Will HNE give my PHI to my family or friends?
We will only disclose your PHI to a member of your family (including your spouse), a relative, or a close friend in the following circumstances:
• You have authorized us to do.
• That person has submitted proof of legal authority to act on your behalf.
• That person is involved in your health care or payment for your health care and needs your PHI for these purposes. If you are present for such a disclosure (whether in person or on a telephone call), we will either seek your verbal agreement to the disclosure or provide you an opportunity to object to it. We will only release the PHI that is directly relevant to their involvement.
• We may share your PHI with your friends or family members if professional judgment says that doing so is in your best interest. We will only do this if you are not present or you are unable to make health care decisions for yourself. For example, if you are unconscious and a friend is with you, we may share your PHI with your friend so you can receive care.
• We may disclose a minor child’s PHI to their parent or guardian. However, we may be required to deny a parent’s access to a minor’s PHI, for example, if the minor is an emancipated minor or can, under law, consent to their own health care treatment.
Will HNE disclose my personal health information to anyone outside of HNE?
HNE may share your protected health information with affiliates and third party “business associates” that perform various activities for us or on our behalf. For example, HNE may delegate certain functions, such as medical management or claims repricing, to a third party that is not affiliated with HNE. HNE may also share your personal health information with an individual or company that is working as a contractor or consultant for HNE. HNE’s financial auditors may review claims or other confidential data in connection with their services. A contractor or consultant may have access to such data when they repair or maintain HNE’s computer systems. Whenever such an arrangement involves the use or disclosure of your protected health information, we will have a written contract that contains terms designed to protect the privacy of your protected health information.
HNE may also disclose information about you to your Primary Care Physician, other providers that treat you and other health plans that have a relationship with you, for their treatment, payment and some of their health care operations.
Will HNE disclose my personal health information to my employer?
In general, HNE will only release to your employer enrollment and disenrollment information, information that has been de-identified so that your employer can not identify you or summary health information. If your employer would like more specific PHI about you to perform plan administration functions, we will either get your written permission or we will ask your employer to certify that they have established procedures in their group health plan for protecting your PHI, and they agree that they will not use or disclose the information for employment-related actions and decisions. Talk to your employer to get more details.
When does HNE need my written authorization to use or disclose my personal health information?
We have described in the preceding paragraphs those uses and disclosures of your information that we may make either as permitted or required by law or otherwise without your written authorization. For other uses and disclosures of your medical information, we must obtain your written authorization. A written authorization request will, among other things, specify the purpose of the requested disclosure, the persons or class of persons to whom the information may be given, and an expiration date for the authorization. If you do provide a written authorization, you generally have the right to revoke it.
Many members ask us to disclose their protected health information to third parties for reasons not described in this notice. For example, elderly members often ask us to make their records available to caregivers. To authorize us to disclose any of your protected health information to a person or organization for reasons other than those described in this notice, please call our Member Services Department and ask for an Authorization of Personal Representative Form. You should return the completed form to HNE’s Enrollment Department at One Monarch Place, Springfield, MA 01144. You may revoke the authorization at any time by sending us a letter to the same address. Please include your name, address, member identification number and a telephone number where we can reach you.
What are my rights with respect to my PHI?
The following is a brief statement of your rights with respect to your protected health information:
Right to Request Restrictions: You have the right to ask us to place restrictions on the way we use or disclose your protected health information for treatment, payment or healthcare operations or to others involved in your health care. However, we are not required to agree to these restrictions. If we do agree to a restriction, we may not use or disclose your protected health information in violation of that restriction, unless it is needed for an emergency.
Right to Request Confidential Communications: You have the right to request to receive communications of protected health information from us by alternative means or at alternative locations if you clearly state that the disclosure of all or part of that information could endanger you. We will accommodate reasonable requests. Your request must be in writing.
Right to Access Your Protected Health Information: You have the right to see and get a copy of the protected health information about you that is contained in a “designated record set,” with some specified exceptions. Your “designated record set” includes enrollment, payment, claims adjudication, case or medical management records and any other records that we use to make decisions about you. Requests for access to copies of your records must be in writing and sent to the attention of the HNE Legal Department. Please provide us with the specific information we need to fulfill your request. We reserve the right to charge a reasonable fee for the cost of producing and mailing the copies.
Right to Amend Your Protected Health Information: You have the right to ask us to amend any protected health information about you that is contained in a “designated record set” (see above). All requests for amendment must be in writing and on a HNE Request for Amendment form. Please contact the HNE Legal Department to obtain a copy of the form. You also must provide a reason to support the requested amendment. In certain cases, we may deny your request. For example, we may deny a request if we did not create the information, as is often the case for medical information in our records. All denials will be made in writing. You may respond by filing a written statement of disagreement with us, and we would have the right to rebut that statement. If you believe someone has received the unamended protected health information from us, you should inform us at the time of the request if you want them to be informed of the amendment.
Right to Request an Accounting of Certain Disclosures: You have the right to have us provide you an accounting of times when we have disclosed your protected health information for any purpose other than the following: (i) treatment, payment or health care operations; (ii) disclosures to others involved in your healthcare; (iii) disclosures that you or your personal representative have authorized; or (iv) certain other disclosures, such as disclosures for national security purposes. All requests for an accounting must be in writing. We will require you to provide us the specific information we need to fulfill your request. This accounting requirement applies for six years from the date of the disclosure, beginning with disclosures occurring after April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable fee.
Right to Request a Copy of this Notice: If you have received this notice electronically, you have the right to obtain a paper copy of this notice upon request.
Who should I contact if I have a question about this notice or a complaint about how HNE is using my personal health information?
To exercise your rights under this Notice or to file a complaint with HNE, please call us at (413) 787-4004, toll free (800) 310-2835 or TTY/TTD: (800) 439-2370 or write to:
Privacy Officer-Compliance Department
Health New England
One Monarch Place, Suite 1500
Springfield, MA 01144-1500
Complaints to the Federal Government: If you believe your privacy rights have been violated, you also have the right to file a complaint with the Secretary of the Department of Health and Human Services. http://www.hhs.gov/ocr/filing-with-ocr/index.html.
You will not be retaliated against for filing a complaint with us or the federal government.