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.
I. Our legal duty
By law, MetroPlus must protect the privacy of health information that shows who you are. MetroPlus also
has to give you this notice to tell you about our legal duties and our privacy practices -- how MetroPlus
may use and give out ("disclose") your protected health information ("PHI"). By law, MetroPlus must
follow the practices described in our current privacy notice.
II. How we may use and disclose health information about you
A. MetroPlus MUST disclose your PHI:
- To you or someone who has the legal right to act for you (your personal representative),
- To the Secretary of the U.S. Department of Health and Human Services, if necessary, to make sure
your privacy is protected, and
- As required by law.
Your written consent is not required for these disclosures. Examples of disclosures that may be required
by law include: (a) disclosures to government agencies as required by New York laws governing health
maintenance organizations; (b) reporting to public health officials information relating to child abuse,
domestic violence, births, deaths and various diseases; (c) responses to court orders or subpoenas issued
by grand juries or administrative tribunals; and (d) disclosures required to comply with workers'
compensation laws.
B. MetroPlus MAY use and disclose your PHI for the purposes described below.
Under New York law, your consent is required for certain disclosures, except to the extent that such
disclosures are made to the Department of Health for quality assurance or oversight, or are otherwise
required by law. Generally, the required consent is contained in enrollment application and renewal forms.
When making disclosures for these purposes, MetroPlus also must follow federal, state and local laws that
provide special privacy protections for health information relating to HIV, mental health and chemical
dependency treatment.
- Treatment: We may use your PHI and disclose it to health care providers as needed for you to get
the health care you need. For example, a MetroPlus nurse care manager may help to arrange for special
services or medical equipment that your doctor orders. In that case, the care manager may need to
discuss your condition and specific needs with providers in order to make sure that you will get the
right services or equipment when you need them. We also give our pharmacy and dental benefit managers
a limited amount of PHI that they need to provide benefits to members.
- Payment: MetroPlus uses and discloses PHI to pay for services covered by your health plan. For
example, the health care providers who treat you bill us for their services and include PHI on their
bills. MetroPlus uses this information to determine whether the services are covered by the Plan and
how much MetroPlus should pay. We also may review medical records from your doctor or hospital to
decide whether services are medically necessary or to verify an emergency medical condition. In
addition, MetroPlus may disclose your PHI to providers or their billing agents in the Plan's explanation
of payment and in resolving payment disputes.
MetroPlus also may use and disclose your PHI as necessary to get paid for what we do. For example, New
York State pays MetroPlus to manage health plan benefits for enrollees in Medicaid Managed Care, Family
Health Plus, and Child Health Plus programs. MetroPlus discloses a limited amount of PHI in billing the
State and may disclose PHI as necessary to resolve payment disagreements. Also, in order to receive
payment from the State, MetroPlus must fulfill its responsibilities under our contracts with the State
and City of New York. These responsibilities include reporting PHI as required by the State and City
for their oversight and management of these programs. As another example, MetroPlus may use or disclose
your PHI to obtain payment under a contract for reinsurance.
- Health Care Operations: MetroPlus may use and disclose your PHI as necessary to make sure that you receive
quality health care and health plan services. These activities may be performed by our employees or by
business partners under contract to MetroPlus. A few examples are given below.
In order to provide customer services, we may use your PHI and may disclose it to contracted providers or
business associates. For example, to investigate and resolve a complaint or problem that is brought to our
attention, our staff may need to discuss the situation, including some of your PHI, with people inside and
outside of MetroPlus. As another example, MetroPlus gives a limited amount of member contact and coverage
information to the company that operates our after hours health care hotline, so that its representatives
can connect you by phone to health care providers.
MetroPlus may use and disclose PHI about you (for example, by calling you or sending you a letter) to remind
you of an appointment for treatment or that it's time for you to schedule an appointment for a regular
check-up or immunization, or to provide information about treatment alternatives ("choices") or other
health-related benefits and services that may be of interest to you.
Quality management also may involve use and disclosure of your PHI. This includes evaluating the performance
of our employees, contracted providers and business partners, as well as monitoring and improving the quality
of the Plan's programs, data and business processes. As an example, your medical record may be reviewed by
our quality management staff or contracted nurse reviewers to evaluate the quality of care provided to you
and all Plan members.
Other examples of MetroPlus activities that are part of health plan operations and may involve use and
disclosure of your PHI include: premium rate filings and other activities involved in contracting to provide
health coverage; financial audits; business planning and development; licensure, certification and
accreditation reviews; internal compliance reviews; obtaining legal services and handling legal matters,
and; fraud prevention and detection.
- Government agency health oversight activities authorized by law. For example, we will give information
to help the government conduct an investigation or inspection of a health care provider.
- Public health agency activities authorized by law. For example, we provide information to assist the
NYC Department of Health in maintaining its childhood immunization registry.
- Disclosure to prevent a serious and imminent threat to your health and safety or to the health and safety
of another person or the public, to someone who can help prevent the threat.
- Law enforcement purposes, such as when required by a court ordered warrant or to report criminal conduct
at the health plan.
- Specialized government functions authorized by law. If you are a member or veteran of the armed forces,
we may disclose PHI about you as required by military authorities. We also may disclose PHI to authorized
federal officials for national security activities. In addition, we may disclose inmates' PHI to correctional
institutions in limited circumstances.
III. Your authorization is required for other uses and disclosures
MetroPlus is required by law to get your written permission (an "authorization") to use or disclose your
PHI for any purpose that is not included in one of the categories of uses and disclosures described in this
notice. You may take back ("revoke") your authorization at any time by writing a letter to the MetroPlus
Privacy Officer. Your letter will be effective as of the date it is received at MetroPlus but we cannot take
back any disclosures already made.
IV. Your other health information privacy rights
- To see and get a copy of your PHI. In most cases, you have the right to look at or get a copy of health
information about you that we may use to make decisions about you. Requests must be sent in writing to the
MetroPlus Privacy Officer. If we don't have your PHI but we know who does, we will tell you who to ask for
it. We will respond to you within 30 days after receiving your written request. In certain situations, we
may deny your request. If we do, we will tell you in writing our reasons for the denial and explain your
right to have the denial reviewed.
As allowed by law, we will charge you $0.75 (75 cents) for each page of copies you request. Instead of
providing the PHI you requested, we may give you a summary or explanation of the PHI as long as you agree
to that and to the cost in advance.
- To have your PHI corrected or updated ("amended") if you believe there is a mistake in it, or that a
piece of important information is missing, and we agree. You must send a request and your reasons for it in
writing to the MetroPlus Privacy Officer. We will respond within 60 days of receiving your request. If we
are unable to act within 60 days, we may extend that time by no more than an additional 30 days. If we need
to extend the time, we will tell you about the delay and the date by which we will complete action on your
request. If we approve your request, we will make the change to your PHI and tell you that we have done
it. If we know or you tell us that someone else received the PHI we agree to amend, we will also tell them
about the correction.
We may deny your request if it is not in writing or does not include a reason to support the request. In
addition, we may deny your request if:
- the information was not created by us, unless the person or entity that created the information is no
longer available to make the correction;
- the information is not in records that you have a right to see or copy;
- we are not permitted by law to disclose the PHI; or
- the PHI is correct and complete.
Our written denial will state the reasons for the denial and explain your right to file a written statement
of disagreement. If you don't file one, you have the right to ask that your request letter and our denial
be attached to all future disclosures of the PHI.
- To get a listing (an "accounting") of disclosures we have made of PHI about you. The list will not
include instances where your PHI was given directly to you or your personal representative or given to
others with your authorization. The list also won't include disclosures made for treatment, payment or
health care operations, or for national security purposes, to corrections or law enforcement personnel, or
before April 14, 2003.
To get an accounting of disclosures, send a written request to the MetroPlus Privacy Officer. Your request
must state a time period that may not be longer than six years and may not include dates before April 14,
2003. We will act on your request within 60 days if possible. If we need more time, we may take up to 30
more days. The first list you request in a 12-month period will be free. We are entitled to charge you for
the cost of providing any more lists within 12 months of providing a free one. We will tell you the cost and
you may choose to withdraw or modify your request before any costs are incurred.
- To ask MetroPlus to restrict or limit how we use or disclose PHI about you for treatment, payment and
health care operations. We will consider your request, but by law we do not have to agree to it. If we do
agree, we will comply with your request unless the information is needed by a provider to give you emergency
treatment or a disclosure is required by law.
To ask for a restriction, write to the MetroPlus Privacy Officer. Your request must tell us: (1) what
information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom
you want the limits to apply - for example, to your spouse or parent.
- To ask for confidential communications. You have the right to ask us to communicate
PHI to you in a
certain way or at a certain location. For example, you can ask us to contact you by phone only at your
work number, or only by mail sent to a particular address. We will accommodate all reasonable requests
that we are able to meet. To ask for confidential communications, call our Member Services Department at
1-800-303-9626 (TDD 1-800-881-2812).
- To get a paper copy of this notice. You may get a paper copy of this notice at any
time by calling
our Member Services Department at 1-800-303-9626 (TDD 1-800-881-2812).
V. Changes to privacy practices and this notice
We reserve the right to change our privacy practices and this notice at any time in accordance with law.
These changes will apply to all information about you that we maintain. If we make a significant change,
we will send you a new notice by mail before the change goes into effect.
VI. Complaints
If you think MetroPlus has violated your privacy rights, you may file a complaint with our Privacy Officer
at the address or phone number below, or you may call Member Services at 1-800-303-9626 (TDD 1-800-881-2812).
You also may send a written complaint to the U.S. Department of Health and Human Services. We will not take
any action against you for filing a complaint.
VII. Privacy Officer contact information
If you have questions about our privacy practices, or if you want to file a complaint or exercise rights
described in section IV, items A, B, C and D above, please contact:
MetroPlus Privacy Officer
160 Water St., 3rd Floor
New York, New York 10038
Phone: (212) 908-8600 Fax: (212) 908-8620
E-mail: MetroPlusPrivacyOfficer@nychhc.org
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