MPG - Member Privacy Notice

Member Privacy Notice

Member Privacy Notice

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, MetroPlusGold must protect the privacy of health information that shows who you are. MetroPlusGold also has to give you this notice to tell you about our legal duties and our privacy practices -- how MetroPlusGold may use and give out ("disclose") your protected health information ("PHI"). By law, MetroPlusGold must follow the practices described in our current privacy notice.

II. How We May Use and Disclose Health Information About You

A. MetroPlusGold Must disclose your PHI (Private Health Information):

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. MetroPlusGold 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, MetroPlusGold 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 MetroPlusGold 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: MetroPlusGold 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. MetroPlusGold uses this information to determine whether the services are covered by the Plan and how much MetroPlusGold 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, MetroPlusGold may disclose your PHI to providers or their billing agents in the Plan's explanation of payment and in resolving payment disputes.

MetroPlusGold may also use and disclose your PHI as necessary to get paid for what we do. For example, New York State pays MetroPlusGold to manage health plan benefits for enrollees in Medicaid Managed Care, Family Health Plus, and Child Health Plus programs. MetroPlusGold 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, MetroPlusGold 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, MetroPlusGold may use or disclose your PHI to obtain payment under a contract for reinsurance.

Health Care Operations: MetroPlusGold 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 MetroPlusGold. 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 MetroPlusGold. As another example, MetroPlusGold 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.

MetroPlusGold 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 MetroPlusGold 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

MetroPlusGold 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 MetroPlusGold Privacy Officer. Your letter will be effective as of the date it is received at MetroPlusGold but we cannot take back any disclosures already made.

IV. Your other health information privacy rights

The collection of information through this website and the disclosure of that information are subject to the provisions of the Internet Security and Privacy Act. MetroPlusGold will only collect personal information through this website or disclose personal information collected through this website if the user has consented to the collection or disclosure of such personal information. Participation in an online transaction resulting in the disclosure of personal information to MetroPlusGold by the user, whether solicited or unsolicited, constitutes consent to the collection and disclosure of the information by MetroPlusGold for the purposes reasonably ascertainable from the nature and terms of the transaction.

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 MetroPlusGold 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 MetroPlusGold 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 MetroPlusGold 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 MetroPlusGold 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 MetroPlusGold 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 Customer Services Department at 1.877.475.3795 (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 Customer Services Department at 1.877.475.3795 (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 MetroPlusGold 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 Customer Services Department at 1.877.475.3795 (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:

MetroPlusGold Privacy Officer
160 Water St., 3rd Floor
New York, New York 10038
Phone: (212) 908-8600
Fax: (212) 908-8620

E-mail: MetroPlusGoldPrivacyOfficer@nychhc.org

Home | Contact Us | About MetroPlusGold | Privacy Policies | 1.877.475.3795