Member Consent. Health Insurance Portability and Accountability Act (HIPAA). Confidentiality of HIV-related Information. Confidentiality of Behavioral Health and ...
MEMBER POLICIES AND RIGHTS TABLE OF CONTENTS .C.O. .P. A. .Y. M. . .E.N. .T. .P.O. .L.I.C. Y. . A. .N. .D. .P. R. .O. .C. E. .D. .U. R. .E. S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6.3. . . .P.r.e.v. e. .n.t.iv. e. .S. e. .r.v.ic. e. .s. C. .o. v. e. .r.e.d. .U. n. .d.e. r. .t.h.e. .A. f.f.o.r.d. a. .b.le. .H. .e.a. l.t.h. .C. a. .re. .A. .c.t. . . . . . . . . . . . . . . . . . . . . . . . 6. .4. . . . . .R.I.G. H. . T. .S. A. .N. .D. .R. E. .S.P. O. .N. .S.I.B. I.L. I.T. I.E. S. .O. .F. .E.M. . B. .L.E. M. . .H. E. .A. L. T. .H. .P. L. .A.N. . M. . .E.M. .B. .E.R. S. . . . . . . . . . . . . . . . . . . . . .6.4. . . .M. .E.M. .B. .E.R. .R. I.G. .H. .T.S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6.7. . . .C. o. .n.f.id. .e.n.t.i.a.li.t.y. .o.f. P. .e.r.s.o. n. .a.l.I.n.f.o.r.m. .a.t.i.o.n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. .7. . . . . .C.o. .n.f.id. .e.n.t.i.a.li.t.y. .o.f. H. .e. a. l.t.h. .I.n.f.o.r.m. .a.t.i.o.n. .f.o.r. M. . i.n. o. .r.s. E. .n.r.o. l.le. .d. .in. .M. . e. d. .ic. .a.id. .M. . a. n. .a.g. e. d. . C. .a. r.e. .P. l.a.n. s. . . . . . . 68 .M. .e.m. .b.e. r. .C. o. .n.s.e. n. .t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. .8. . . . . .H. e. .a.lt. h. .I.n.s. u. .ra. .n.c.e. .P. o. .r.t.a.b.i.li.t.y. a. .n.d. .A. c. c. .o.u. n. .ta. .b.i.li.t.y. A. .c.t. (. H. .I.P. A. .A. ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. .9. . . . . .C.o. n. .f.id. .e.n.t.i.a.li.t.y. .o.f.H. .I.V. -.r.e. l.a.t.e. d. .I.n.f.o. r.m. .a. t.i.o.n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. .9. . . . . .C.o. n. .f.id. .e.n.t.i.a.li.t.y. o. .f.B. .e.h.a. v. .io. r. a. .l .H. e. .a.lt. h. .a. n. .d. S. .u.b. s. t. a. n. .c.e. .U. s. e. .I.n.f.o. r. m. .a. t. i.o.n. . . . . . . . . . . . . . . . . . . . . . . . 6. .9. . . . . .R.o. u. .ti.n. e. .C. .o.n. s. e. .n.t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. .0. . . . . .A.u. t. h. .o.r.iz. .a.t.io. .n. t. o. .R. .e.le. .a.s.e. .In. .f.o.r.m. .a.t.io. .n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. .0. . . . . .A.c.c. e. .s.s.t.o. .M. .e. d. .ic. a. l. .R.e. c. .o.r.d.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. .0. . . . . .N. o. .n.d. i.s.c. r. i.m. .in. .a.t.i.o.n. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. .0. . . . . .C. u. .lt.u. r. a. l. .C. o. .m. .p.e.t.e.n. .c.y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. .1. . . . . .N. o. .t.ic. e. .o. f. .P.r.i.v.a.c. y. .P. r. a. .c.t.ic. e. .s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. .1. . . . . Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 62 MEMBER POLICIES AND RIGHTS In the chapter, you will find information on our member copay policy and procedures, along with members' rights and responsibilities, including privacy right. COPAYMENT POLICY AND PROCEDURES Some plan members have required copayment (copay) charges. Copays should be collected from members by the provider's office at the time of service. The copay, in conjunction with an office visit, is part of the provider's remuneration and its collection is the provider's responsibility. In the event that the copay is not collected from the member, the provider may not seek reimbursement of the copay from EmblemHealth. If the contracted fee under the participating provider agreement with the EmblemHealth companies is less than the copay amount, the participating provider is not permitted to collect the difference between the contracted fee and the copay and must refund such difference to the member if it was collected. Members with a Select Care Network-based benefit plan may have a deductible for in-network services. When collecting a copay at an office visit, please note that this amount may actually be a payment towards the member's deductible and that a true copay will not apply until after the deductible is met. Please see the remittance statement for the member's actual out-of-pocket responsibility. Patient-specific copay information is listed on the member's ID card. It can also be obtained from our secure website at emblemhealth.com in the member's Summary of Benefits or from our Customer Service departments as listed in the Directory chapter. Important things to note: Copays may not be collected from Medicare members for the preventive care services as defined by CMS and listed in Appendix C. Members enrolled in Dual Eligible PPO SNP, Dual Eligible HMO SNP and GuildNet Gold plans may not be charged cost-sharing greater than what would have been charged if the member was enrolled in NYS Medicaid. Medicaid members do not have copays for the following services: Emergency room visits for needed emergency care Family planning services, drugs and supplies Mental health visits Chemical dependency visits Drugs to treat mental illness Drugs to treat tuberculosis Prescription drugs for residents of adult care facilities The following Medicaid members do not have copays for any services: Children under age 21 Pregnant women (through 60 days postpartum) Permanent residents of nursing homes Residents of community-based residential facilities licensed by the Office of Mental Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 63 MEMBER POLICIES AND RIGHTS Health or the Office of Mental Retardation and Developmental Disability Those who are financially unable to make copays at any time and who tell the provider they are unable to pay Medicaid members in a Comprehensive Medicaid Case Management (CMCM) or service coordination program Medicaid members in an OMH or OPWDD Home and Community-Based Services (HCBS) waiver program Medicaid members in a DOH HCBS waiver program for persons with traumatic brain injury (TBI) Medicaid members cannot be denied health care services based on their inability to pay the copay at the time of service. However, providers may bill these members or take other action to collect the owed copay amount. Members with Medicaid have only pharmacy copays and an annual $200 maximum copay obligation. There are no plan copay requirements for CHPlus members. Copays may not exceed the amount payable under the participating provider agreement. Preventive Services Covered Under the Affordable Health Care Act The Affordable Health Care Act dictates that any person who has a new insurance plan or policy as of September 23, 2010 must have certain preventive services covered without having to pay a copay or coinsurance or meet a deductible. Our Preventive Health Guidelines booklet (available at emblemhealth.com/en/Health-and-Wellness/PHG-Introduction.aspx) helps members learn more about the screenings, tests and immunizations that they and their family need every year. RIGHTS AND RESPONSIBILITIES OF EMBLEMHEALTH PLAN MEMBERS The rights and responsibilities listed below indicate what members can expect of EmblemHealth and what responsibilities our members have to EmblemHealth. EmblemHealth plan members have the right to: Be treated without discrimination, including discrimination based on race, color, religion, gender, national origin, disability, sexual orientation or source of payment. Participate with physicians in making decisions about their health care. A non-smoking environment. Be treated with fairness and respect at all times, and in a clean and safe environment. Receive, upon request, a list of the physicians and other health care providers in our participating provider network. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 64 Change their physician. MEMBER POLICIES AND RIGHTS Information about our plans and networks and their covered services. Be assured that our participating health care providers have the qualifications stated in our Professional Standards, established by the EmblemHealth Credentialing Committee, which are available upon request. Know the names, positions and functions of any participating provider's staff and to refuse their treatment, examination or observation. Timely access to covered services and drugs. Obtain from their physician, during practice hours, comprehensive information about their diagnosis, treatment and prognosis, regardless of cost or benefit coverage, in language they can understand. When it is not medically advisable to give them such information, or when the member is a minor or is incompetent, the information will be made available to a person who has been designated to act on that person's behalf. Receive from their physician the information necessary to allow them to give informed consent prior to the start of any procedure or treatment and to refuse to participate in, or be a patient for, medical research. In deciding whether to participate, they have the right to a full explanation. Know any risks involved in their care. Refuse treatment, to the extent permitted by law, and to be informed of the medical consequences of refusing it. Have all lab reports, X-rays, specialists' reports and other medical records completed and placed in their chart so they may be available to their physician at the time of consultation. Be informed about all medication given to them, as well as the reasons for prescribing the medication and its expected effects. Receive, from their provider, all information they need to give informed consent for an order not to resuscitate. They also have the right to designate an individual to give this consent if they are too ill to do so. Request a second opinion from a participating physician. Privacy concerning their medical care. This means, among other things, that no person who is not directly involved in their care may be present without their permission during any portion of their discussion, consultation, examination or treatment. We will give them a written notice, called a "Notice of Privacy Practice," that describes their rights. Expect that all communications, records and other information about their care or personal condition will be kept confidential, except if disclosure of that information is required by law or permitted by them. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 65 MEMBER POLICIES AND RIGHTS Request that copies of their complete medical records be forwarded to a physician or hospital of their choice at their expense. However, information may be withheld from them if, in the physician's judgment, release of the information could harm them or another person. Additionally, a parent or guardian may be denied access to medical records or information relating to a minor's pregnancy, abortion, birth control or sexually transmitted diseases if the minor's consent is not obtained. Have a person of their choice accompany them in any meeting or discussion with medical or administrative personnel. Give someone legal authority to make medical decisions for them. Consult by appointment, during business hours, with our responsible administrative officials and their participating physician's office to make specific recommendations for the improvement of the delivery of health services. Make a complaint or file an appeal related to the organization or a determination about seeking care or about care and services they have received. See information on filing member appeals. Receive an explanation from us if a provider has denied care that they believe they should receive. To receive this explanation, they will need to ask us for a copy of the written decision. Receive from us information in a way that works for them, in languages other than English or other alternate formats, in accordance with company policy and regulatory rules. IMPORTANT: State and federal laws give adults in New York State the right to accept or refuse medical treatment, including life-sustaining treatment, in the event of catastrophic illness or injury. EmblemHealth makes available materials on advance directives with written instructions, such as a living will or health care proxy containing the members' wishes relating to health care should they become incapacitated. If members live in another state, they should check with their local state insurance department, if available, for information on additional rights they may have. Receive information about our organization, our services and our provider networks and about member rights and responsibilities. Make recommendations regarding our member rights and responsibilities policies. EmblemHealth plan members have the responsibility to: Provide us and our participating physicians and other providers with accurate and relevant information about their medical history and health so that appropriate treatment and care can be rendered. They should tell their doctors they are enrolled in our plan and show them their membership card. Keep scheduled appointments or cancel them, giving as much notice as possible in accordance with the provider's guidelines for cancelation notification. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 66 MEMBER POLICIES AND RIGHTS Update their record with accurate personal data, including changes in name, address, phone number, additional health insurance carriers and an increase or decrease in dependents within 30 days of the change. Treat with consideration and courtesy all of our personnel and the personnel of any hospital or health facility to which they are referred. Be actively involved in their own health care by seeking and obtaining information, by discussing treatment options with their physician and by making informed decisions about their health care. Participate in understanding the member's health issues and to follow through with treatment plans agreed upon by all parties in the member's health care: the member, EmblemHealth and participating physicians. Follow plans and instructions for care that they have agreed to with their practitioner. Understand their health problems and participate in developing mutually agreed upon treatment goals, to the degree possible. Understand our benefits, policies and procedures as outlined in their Contract or Certificate of Coverage and handbook, including policies related to prior approval for all services that require such approval. Pay premiums on time and to pay copayments, if applicable, at the time services are rendered. Abide by the policies and procedures of their participating physician's office. Notify us if they have any other health insurance or prescription drug coverage in addition to our plan. Be considerate. We expect them to respect the rights of other patients and act in a way that helps the smooth running of their doctors' office, hospitals and other offices. MEMBER RIGHTS The protection and security of our members' personal information is a major objective of EmblemHealth. Our Notice of Privacy Practices describes how medical information about our members may be used and disclosed and how our members can get access to this information. Our member handbook tells members how to give consent to the collection, use and release of personal health information, how to obtain access to their medical records and what we do to protect access to their personal information. We are also committed to serving our members in a culturally competent and nondiscriminatory manner. Confidentiality of Personal Information As members consider joining an EmblemHealth plan, we want them to know that we make the Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 67 MEMBER POLICIES AND RIGHTS protection of personal information a high priority. Our members entrust us with information that is personal, sensitive and highly confidential. Our employees and other authorized individuals working for us are accountable for exercising a high degree of care in safeguarding the confidentiality of that information. Indeed, our employees and other authorized individuals are prohibited from: Accessing or trying to access personal information, except on a "need to know" basis and only when authorized to do so. Disclosing personal information to any person or organization within or outside the Plan, unless that person or organization has a "need to know" and is authorized by us to receive that information. Confidentiality of Health Information for Minors Enrolled in Medicaid Managed Care Plans Effective September 1, 2016, EmblemHealth will suppress all Explanation of Benefits (EOBs) for Medicaid minors 0 under 18 years of age, with the exception of dental-related services and situations where the member may be financially responsible. New York State Department of Health (DOH) requires Medicaid Managed Care Plans, including EmblemHealth, to establish an effective, uniform and systemic mechanism to comply with confidentiality protections for health care services provided to minors who are enabled by statute to consent to their own heath care. Member Consent Providers should be aware of who may and may not consent for care. Public Health Law section 2504 specifically states the following: Any person who is 18 years of age or older, or is the parent of a child or has married, may give effective consent for medical, dental, health and hospital services for himself or herself, and the consent of no other person is necessary. Any person who has been married or who has borne a child may give effective consent for medical, dental, health and hospital services for his or her child. Any person who has been designated by law as a person in parental relation to a child may consent to any medical, dental, health and hospital services for such child for which consent is otherwise required. The above excludes (a) major medical treatment as defined in the mental hygiene law; (b) electroconvulsive therapy; and (c) the withdrawal or discontinuance of medical treatment that is sustaining life functions. Any person who is pregnant may give effective consent for medical, dental, health and hospital services relating to prenatal care. Medical, dental, health and hospital services may be rendered to persons of any age without the consent of a parent or legal guardian when, in the physician's judgment an emergency exists and the person is in immediate need of medical attention and an attempt to secure consent would result in a delay of treatment that would increase the risk to the person's life or health. Where not otherwise already authorized by law to do so, any person in a parental relation to a child as defined by law as well as (i) a grandparent, an adult brother or sister, or an adult aunt or uncle, any of whom has assumed care of the child and (ii) an adult who has care of the Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 68 MEMBER POLICIES AND RIGHTS child and has written authorization to consent from a person in a parental relation to a child as defined by law may give effective consent for the immunization of a child. However, a person other than one in a parental relation to the child cannot give consent under this subdivision if he or she has reason to believe that a person in parental relation to the child (as defined by law) objects to the immunization. Anyone who acts in good faith based on the representation by a person that he or she is eligible to consent pursuant to the terms of this section shall be deemed to have received effective consent. Health Insurance Portability and Accountability Act (HIPAA) HIPAA requires providers to take reasonable and appropriate measures to protect member/patient information. Examples of measures considered reasonable and appropriate to safeguard the patient chart include limiting access to certain areas, ensuring that the area is supervised, escorting non-employees in the area, and placing the patient chart in the box with the front cover facing the wall so that protected health information is not visible to anyone who walks by. An office sign-in sheet may not display medical information that is unnecessary for the purpose of signing in (e.g., information about symptoms or treatment). In addition, while providers may leave messages for members on home answering machines, they should consider leaving only the member's name on the machine along with information necessary to confirm an appointment, or simply asking the individual to call back. Confidentiality of HIV-related Information The provider must develop policies and procedures to assure confidentiality of HIV-related information. These policies and procedures must include: Initial and annual in-service education of staff and contractors Identification of staff allowed access and limits of access Procedures to limit access to trained staff (including contractors) Protocols for secure storage (including electronic storage) Procedures for handling requests for HIV-related information Protocols to protect persons with or suspected of having HIV infection from discrimination Confidentiality of Behavioral Health and Substance Use Information Each provider must develop policies and procedures to assure confidentiality of mental health and substance related information. These policies and procedures must include: Initial and annual in-service education of staff and contractors Identification of staff allowed access and limits of access Procedures to limit access to trained staff (including contractors) Protocols for secure storage (including electronic storage) Procedures for handling requests for BH/SU information protocols to protect persons with behavioral health and/or substance use disorder from discrimination Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 69 MEMBER POLICIES AND RIGHTS Routine Consent Before releasing personal information, consent must first be obtained from the member or a qualified person, unless release of that information is required by law. In many cases, when new members enroll in an EmblemHealth plan, routine consent for release of information is obtained on the enrollment application. The consent authorizes the use of personal information for general treatment, coordination of care, quality assessment, utilization review and fraud detection. The consent also authorizes the use of personal information for oversight reviews, such as those performed by the state or for accreditation purposes. In addition, it covers future routine use of such information. HIPAA permits the disclosure of information for payment, treatment and health care operations. Authorization to Release Information Authorization must be obtained from the member or qualified person before any personal health information can be released to an outside organization or agency, unless release of that information is legally required or permitted. Special restrictions apply to the release of information relating to alcohol and drug abuse, abortion, sexually transmitted disease, adoption, psychiatric treatment, psychotherapy notes and HIV/AIDS. Access to Medical Records Our providers maintain medical records for the benefit of our members. A member has the right to review, copy and request amendments to his or her medical record. Any member or qualified person who desires a copy of the medical record may obtain one by submitting a written request to his or her network or facility. A member or qualified person may challenge the accuracy of the information in the medical record. In addition, he or she may require that a statement describing the challenge be added to the record. Access by a member or qualified person to information in the medical record may be denied, but only if the network provider or facility determines that: Access can reasonably be expected to cause substantial harm to the member or to others Access would have a detrimental effect on the network practitioner's or facility's professional relationship with the member, or on their ability to provide treatment Nondiscrimination The network provider represents and warrants to EmblemHealth that he or she will not discriminate against members with respect to the availability or provision of health services based on a member's race, ethnicity, creed, sex, age, national origin, religion, place of residence, HIV status, source of payment, plan membership, color, sexual orientation, marital status, veteran status, or any factor related to a member's health status, including, but not limited to, a member's mental or physical disability or medical condition or handicap or other disability, claims experience, receipt of health care, medical history, genetic information or type of illness or condition, evidence of insurability (including conditions arising out of acts of domestic Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 70 MEMBER POLICIES AND RIGHTS violence), disability or on any other basis otherwise prohibited by state or federal law. Further, the provider shall comply with Title VI of the Civil Rights Act of 1964, as implemented by regulations at 45 C.F.R. part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. part 91; other laws applicable to recipients of federal funds; and all other applicable laws and rules, as required by applicable laws or regulations. The provider shall not discriminate against a member based on whether or not the member has executed an advance directive. The provider acknowledges that EmblemHealth is receiving federal funds and that payments to the provider for covered services are in whole or in part from federal funds. Cultural Competency The US Department of Health & Human Services defines cultural and linguistic competence as a set of congruent behaviors, attitudes and policies that come together in a system or agency or among professionals and enable effective work in cross-cultural situations. Delivering quality, sensitive care to a diverse cross-cultural population promotes respectful and responsive health care without cultural communication differences hindering the relationship. For additional information regarding cultural and linguistic competence, as well as educational materials and online courses, the following resources are available: · US Department of Health & Human Services: The Office of Minority Health · AHRQ: Setting the Agenda for Research on Cultural Competence in Health Care · America's Health Insurance Plans: Tools to Address Disparities in Health · EmblemHealth Learn Online: Cultural Competency In addition, EmblemHealth encourages its providers (medical, physical, behavioral, long term services and support [LTSS] and pharmacy) to consider how people's religious beliefs and practices intersect with medical science. We recognize that cultural competence is particularly important to the diverse cultural and religious identities of our members and the communities we serve. That is why we sponsored Tanenbaum Center for Interreligious Understanding to write The Medical Manual for Religio-Cultural Competency. It is user-friendly and filled with information for the busy health care practitioner who wants to be religio-culturally competent. Its wide-ranging chapters not only include practical information on the various religions, but also spiritual assessment forms and tools and tips for working effectively with people of diverse religious backgrounds and points of view. As a leader in providing coverage of innovative and evidence-based approaches to health care, EmblemHealth is pleased to offer this firstof-its-kind publication to our network practitioners. Log on to emblemhealth.com to access The Medical Manual. Notice of Privacy Practices See the following page for our Notice of Privacy Practices. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 71 MEMBER POLICIES AND RIGHTS 7248B 13001092 IMPORTANT INFORMATION ABOUT YOUR PRIVACY RIGHTS NOTICE OF PRIVACY PRACTICES Effective September 1, 2013 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. EmblemHealth, Inc. is the parent organization of the following companies that provide health benefit plans: Group Health Incorporated (GHI), HIP Health Plan of New York (HIP) and HIP Insurance Company of New York, Inc. (HIPIC). All of these entities receive administrative and other services from EmblemHealth Services Company LLC which is also an EmblemHealth, Inc. company. This notice describes the privacy practices of EmblemHealth companies, including GHI, HIP and HIPIC (collectively "the Plan"). We respect the confidentiality of your health information. We are required by federal and state laws to maintain the privacy of your health information and to send you this notice. This notice explains how we use information about you and when we can share that information with others. It also informs you about your rights with respect to your health information and how you can exercise these rights. We use security safeguards and techniques designed to protect your health information that we collect, use or disclose orally, in writing and electronically. We train our employees about our privacy policies and practices, and we limit access to your information to only those employees who need it in order to perform their business responsibilities. We do not sell information about our customers or former customers. How We Use or Share Information We may use or share information about you for purposes of payment, treatment and health care operations, including with our business associates. For example: · Payment: We may use your information to process and pay claims submitted to us by you or your doctors, hospitals and other health care providers in connection with medical services provided to you. · Treatment: We may share your information with your doctors, hospitals, or other providers to help them provide medical care to you. For example, if you are in the hospital, we may give the hospital access to any medical records sent to us by your doctor. · Health Care Operations: We may use and share your information in connection with our health care operations. These include, but are not limited to: Sending you a reminder about appointments with your doctor or recommended health screenings. Giving you information about alternative medical treatments and programs or about health-related products and services that you may be interested in. For example, we might send you information about stopping smoking or weight loss programs. Performing coordination of care and case management. Conducting activities to improve the health or reduce the health care costs of our members. For example, we may use or share your information with others to help manage your health care. We may also talk to your doctor to suggest a disease management or wellness program that could help improve your health. Managing our business and performing general administrative activities, such as customer service and resolving internal grievances and appeals. Conducting medical reviews, audits, fraud and abuse detection, and compliance and legal services. Conducting business planning and development, rating our risk and determining our premium rates. However, we will not use or disclose any of your genetic information for underwriting purposes. Reviewing the competence, qualifications, or performance of our network providers, and conducting training programs, accreditation, certification, licensing, credentialing and other quality assessment and improvement activities. · Business Associates: We may share your information with others who help us conduct our business operations, provided they agree to keep your information confidential. Other Ways We Use or Share Information We may also use and share your information for the following other purposes: · We may use or share your information with the employer or other health-plan sponsor through which you receive your health benefits. We will not share individually identifiable health information with your benefits plan unless they promise Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies 50-8087 3/16 Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 72 MEMBER POLICIES AND RIGHTS to keep it protected and use it only for purposes relating to the administration of your health benefits. · We may share your information with a health plan, provider, or health care clearinghouse that participates with us in an organized health care arrangement. We will only share your information for health care operations activities associated with that arrangement. · We may share your information with another health plan that provides or has provided coverage to you for payment purposes. We may also share your information with another health plan, provider or health care clearinghouse that has or had a relationship with you for the purpose of quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, or detecting or preventing health care fraud and abuse. · We may share your information with a family member, friend, or other person who is assisting you with your health care or payment for your health care. We may also share information about your location, general condition, or death to notify or help notify (including identifying and locating) a person involved with your care or to help with disaster-relief efforts. Before we share this information, we will provide you with an opportunity to object. If you are not present, or in the event of your incapacity or an emergency, we will share your information based on our professional judgment of whether the disclosure would be in your best interest. State and Federal Laws Allow Us to Share Information There are also state and federal laws that allow or may require us to release your health information to others. We may share your information for the following reasons: · We may report or share information with state and federal agencies that regulate the health care or health insurance system such as the U.S. Department of Health and Human Services, the New York State Department of Financial Services and the New York State Department of Health. · We may share information for public health and safety purposes. For example, we may report information to the extent necessary to avert an imminent threat to your safety or the health or safety of others. We may report information to the appropriate authorities if we have reasonable belief that you might be a victim of abuse, neglect, domestic violence or other crimes. · We may provide information to a court or administrative agency (for example, in response to a court order, search warrant, or subpoena). · We may report information for certain law enforcement purposes. For example, we may give information to a law enforcement official for purposes of identifying or locating a suspect, fugitive, material witness or missing person. · We may share information with a coroner or medical examiner to identify a deceased person, determine a cause of death, or as 2 authorized by law. We may also share information with funeral directors as necessary to carry out their duties. · We may use or share information for procurement, banking or transplantation of organs, eyes or tissue. · We may share information relative to specialized government functions, such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others, and to correctional institutions and in other law enforcement custodial situations. · We may report information on job-related injuries because of requirements of your state worker compensation laws. · Under certain circumstances, we may share information for purposes of research. Sensitive Information Certain types of especially sensitive health information, such as HIV-related, mental health and substance abuse treatment records, are subject to heightened protection under the law. If any state or federal law or regulation governing this type of sensitive information restricts us from using or sharing your information in any manner otherwise permitted under this Notice, we will follow the more restrictive law or regulation. Your Authorization Except as described in this Notice of Privacy Practices, and as permitted by applicable state or federal law, we will not use or disclose your personal information without your prior written authorization. We will also not disclose your personal information for the purposes described below without your specific prior written authorization: Your signed authorization is required for the use or disclosure of your protected health information for marketing purposes, except when there is a face-to-face marketing communication or when we use your protected health information to provide you with a promotional gift of nominal value. Your signed authorization is required for the use or disclosure of your personal information in the event that we receive remuneration for such use or disclosure, except under certain circumstances as allowed by applicable federal or state law. If you give us written authorization and change your mind, you may revoke your written authorization at any time, except to the extent we have already acted in reliance on your authorization. Once you give us authorization to release your health information, we cannot guarantee that the person to whom the information is provided will not re-disclose the information. We have an authorization form that describes the purpose for which the information is to be used, the time period during which the authorization form will be in effect, and your right to revoke authorization at any time. The authorization form must be completed and signed by you or your duly authorized representative and returned to us before we will disclose any of your protected health information. You can obtain a copy of this form by calling the Customer Service phone number on the back of your ID card. Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 73 MEMBER POLICIES AND RIGHTS Your Rights The following are your rights with respect to the privacy of your health information. If you would like to exercise any of the following rights, please contact us by calling the telephone number shown on the back of your ID card. Restricting Your Information · You have the right to ask us to restrict how we use or disclose your information for treatment, payment or health care operations. You also have the right to ask us to restrict information that we have been asked to give to family members or to others who are involved in your health care or payment for your health care. Please note that while we will try to honor your request, we are not required to agree to these restrictions. Confidential Communications for Your Information · You have the right to ask to receive confidential communications of information if you believe that you would be endangered if we send your information to your current mailing address (for example, in situations involving domestic disputes or violence). If you are a minor and have received health care services based on your own consent or in certain other circumstances, you also may have the right to request to receive confidential communications in certain circumstances, if permitted by state law. You can ask us to send the information to an alternative address or by alternative means, such as by fax. We may require that your request be in writing and you specify the alternative means or location, as well as the reason for your request. We will accommodate reasonable requests. Please be aware that the explanation of benefits statement(s) that the Plan issues to the contract holder or certificate holder may contain sufficient information to reveal that you obtained health care for which the Plan paid, even though you have asked that we communicate with you about your health care in confidence. Inspecting Your Information · You have the right to inspect and obtain a copy of information that we maintain about you in your designated record set. A "designated record set" is the group of records used by or for us to make benefit decisions about you. This can include enrollment, payment, claims and case or medical management records. We may require that your request be in writing. We may charge a fee for copying information or preparing a summary or explanation of the information and in certain situations, we may deny your request to inspect or obtain a copy of your information. If this information is in electronic format, you have the right to obtain an electronic copy of your health information maintained in our electronic record. Amending Your Information · You have the right to ask us to amend information we maintain about you in your designated record set. We may require that your request be in writing and that you provide a reason for your request. We may deny your request for an amendment if we did not create the information that you want amended and the originator remains available or for certain other reasons. If we deny your request, you may file a written statement of disagreement. Accounting of Disclosures · You have the right to receive an accounting of certain disclosures of your information made by us for purposes other than treatment, payment or health care operations during the six years prior to your request. We may require that your request be in writing. If you request such an accounting more than once in a 12-month period, we may charge a reasonable fee. Please note that we are not required to provide an accounting of the following: Information disclosed or used for treatment, payment and health care operations purposes. Information disclosed to you or following your authorization. Information that is incidental to a use or disclosure otherwise permitted. Information disclosed to persons involved in your care or other notification purposes. Information disclosed for national security or intelligence purposes. Information disclosed to correctional institutions or law enforcement officials. Information that was disclosed or used as part of a limited data set for research, public health or health care operations purposes. Collecting, Sharing and Safeguarding Your Financial Information In addition to health information, the plan may collect and share other types of information about you. We may collect and share the following types of personal information: · Name, address, telephone number and/or email address; · Names, addresses, telephone numbers and/or email addresses of your spouse and dependents; · Your social security number, age, gender and marital status; · Social security numbers, age, gender and marital status of your spouse and dependents; · Any information that we receive about you and your family from your applications or when we administer your policy, claim or account; · If you purchase a group policy for your business, information to verify the existence, nature, location and size of your business. · We also collect income and asset information from Medicaid, Child Health Plus, Family Health Plus and Healthy New York subscribers. We may also collect this information from Medicare subscribers to determine eligibility for government subsidized programs. 3 Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 74 MEMBER POLICIES AND RIGHTS We may share this information with our affiliates and with business associates that perform services on our behalf. For example, we may share such information with vendors that print and mail member materials to you on our behalf and with entities that perform claims processing, medical review and other services on our behalf. These business associates must maintain the confidentiality of the information. We may also share such information when necessary to process transactions at your request and for certain other purposes permitted by law. To the extent that such information may be or become part of your medical records, claims history or other health information, the information will be treated like health information as described in this notice. As with health information, we use security safeguards and techniques designed to protect your personal information that we collect, use or disclose in writing, orally and electronically. We train our employees about our privacy policies and practices, and we limit access to your information to only those employees who need it in order to perform their business responsibilities. We do not sell information about our customers or former customers. Write to: Corporate Compliance Dept. P.O. Box 2878 New York, NY 10116-2878 Call: EmblemHealth program members: Monday to Friday, 8 am-6 pm, 1-877-842-3625, TTY: 711 EmblemHealth Medicare members: 7 days a week, 8 am-8 pm PPO: 1-866-557-7300, TTY: 711 HMO: 1-877-344-7364, TTY: 711 PDP (City of NY Retirees): 1-800-624-2414, TTY: 711 PDP (non-City of NY Retirees): 1-877-444-7241, TTY: 711 GHI members: Monday to Friday, 8 am-6 pm, 1-800-624-2414, TTY: 711 HIP "GHI HMO" plan members: Monday to Friday, 8 am-6 pm, 1-877-244-4466, TTY: 711 Exercising Your Rights, Complaints and Questions HIP/HIPIC members: Monday to Friday, 8 am-6 pm, 1-800-447-8255, TTY: 711 · You have the right to receive a paper copy of this notice upon request at any time. You can also view a copy of this notice on the website. See information at the end of this page. We must Medicaid, Family Health Plus and Child Health Plus members: Monday to Friday, 8 am-6 pm, 1-855-283-2146, TTY: 711 abide by the terms of this notice. · If you have any questions or would like further information about this notice or about how we use or share information, Select Care HMO members: Monday to Friday, 8 am-6 pm, 1-888-447-7703, TTY: 711 you may write to the Corporate Compliance department or call Customer Service. Please see the contact information on this page. Personal Information After You Are · If you believe that we may have violated your privacy rights, No Longer Enrolled you may file a complaint. Even after you are no longer enrolled in any plan, we may maintain your personal information as required by law or We will take no action against you for filing a complaint. Call as necessary to carry out plan administration activities on Customer Service at the telephone number and during the hours of your behalf. Our policies and procedures that safeguard that operation listed on this page. You can also file a complaint by mail information against inappropriate use and disclosure still apply to the Corporate Compliance Department at the mailing address on if you are no longer enrolled in the Plan. this page. You may also notify the Secretary of the U.S. Department of Health and Human Services. Changes to this Notice We will notify you in the event of a breach of your unsecured protected health information. We will provide this notice as soon as reasonably possible, but no later than 60 days after our discovery of the breach, or as otherwise required by applicable laws, regulations or contract. We are required to abide by the terms of this Notice of Privacy Practices as currently in effect. We reserve the right to change the terms of the notice and to make the new notice effective for all the protected health information that we maintain. Prior to implementing any material changes to our Contact Information Please check the back of your ID card to call us or use the following contact information for your plan. Read carefully to select the correct Customer Service number. privacy practices, we will promptly revise and distribute our notice to our customers. In addition, for the convenience of our members, the revised privacy notice will also be posted on our website: emblemhealth.com. 4 Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 75 MEMBER POLICIES AND RIGHTS Back to Table of Contents EmblemHealth Provider Manual PDF created on: 06/28/2019 76EmblemHealth Services Co., LLC via ABCpdf