Member Privacy Rights

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.

The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice” contained in your Evidence of Coverage (EOC), that tells about these rights and explains how we protect the privacy of your health information. The same information is provided below.

How do we protect the privacy of your health information?                                                                                                                                                                                                    

We make sure that unauthorized people don’t see or change your records. In most situations, if we give your health information to anyone who is not providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you. There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law.

For example, we are required to release health information to government agencies that are checking on quality of care. Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations.

You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will consider your request and decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that are not routine.

Our pledge regarding medical information

We understand that medical information about you and your health is personal. We are committed to protecting your medical information, including nonpublic personal financial information relating to your healthcare. We create a record of your benefits and eligibility status and claims history. We need this record to provide you with quality healthcare benefits and to comply with certain legal requirements. Hospitals, physicians and other healthcare providers providing healthcare services to Senior Care Plus members may have different policies or notices regarding their uses and disclosures of your medical information.

This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to: Make sure that medical information that identifies you is kept private; Give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of the notice that is currently in effect.

Information about our members

In the course of providing healthcare benefits, we may receive the following information about you:

• Information provided by you on applications, forms, surveys and our Web site, such as your name, address, date of birth, Social Security number, gender, marital status and dependents.
  Information provided by your employer, benefits plan sponsor or association regarding any group product you may have.
• Information about your transactions and experiences with our health plan and our affiliates, such as: services purchased, account balances, payment history, claims history, policy coverage and premiums.
• Information from consumer or medical reporting agencies, medical providers or third parties, such as medical information and demographic information.

How we protect your medical information

At Senior Care Plus, we restrict access to your medical information to those employees who need it to provide services to you and your dependents. We maintain physical, electronic and procedural safeguards to protect your medical information against unauthorized access and use. For example, access to our facilities is limited to authorized personnel and we protect information we maintain electronically through the use of a variety of technical tools. We have also established a Privacy Office, which has overall responsibility for developing, educating company personnel about, and overseeing the implementation of policies and procedures to safeguard medical information against inappropriate access, use and disclosure, consistent with applicable law.

How we may use and disclose medical information about you

Senior Care Plus will not disclose your medical information to anyone, except with your authorization or otherwise as permitted by law. For some activities, we must have your written authorization to use or disclose your medical information. The law, however, permits Hometown Health to use or disclose your medical information for the following purposes without your authorization:

• For Payment: We may use and disclose your medical information in order to pay for your medical benefits under our health plan. These activities may include making benefit determinations and paying claims.
• For Healthcare Operations: We may use and disclose medical information about you for health plan operations. These uses and disclosures are necessary to run the health plan and make sure that all of our members receive quality benefits and customer service. Here are some examples of the ways that we use your medical information for our healthcare operations:
  • Quarterly newsletters that offer members information on various healthcare issues such as asthma, diabetes, and breast cancer.
  • Administration of Hometown Health Plans or contracts, which, where applicable, may involve claims management; utilization review and management; data and information systems management; medical necessity review; coordination of care, benefits and services; response to member inquiries or requests for services; conduct of grievances, appeals and external review programs; benefits and program analysis and reporting; risk management; detection and investigation of fraud and other unlawful conduct; auditing; underwriting and rate making; and other activities described below.
  • Operation of disease and case management programs in plans that offer these programs, through which we or our contractors perform risk and health assessments; identify and contact members who may benefit from participation in disease or case management programs; and send relevant information to those members who enroll in the programs and their providers.
  • Quality assessment and improvement activities, such as peer review and credentialing of participating providers; program development; and accreditation by independent organizations, where applicable.
  • If we are providing health benefits to you as a beneficiary of an employer-sponsored group health plan, we may disclose your Protected Health Information to the sponsor of the plan.
  • Transitioning of policies or contracts from and to other health plans. We may disclose your medical information to another entity that has a relationship with you and is subject to the federal privacy laws, for their healthcare operations relating to quality assessment and improvement activities, reviewing the competence and qualifications of healthcare professionals, or detecting or preventing healthcare fraud and abuse.

• To Your Family and Friends: We may disclose your medical information to a family member, friend or other person to the extent necessary to help with your healthcare or payment for your healthcare. Before we disclose your medical information to a person involved in your healthcare or payment for your healthcare, we will provide you with an opportunity to object to such uses and disclosures. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest.
• As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law. We must also share your medical information with authorities that monitor our compliance with privacy laws.
• To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Special situations

• Military and Veterans. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
• Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:
  • To prevent or control disease, injury or disability;
  • To report births and deaths;
  • To report the abuse or neglect of children, elders and dependent adults;
  • To report reactions to medications or problems with products;
  • To notify people of recalls of products they may be using;
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
  • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

• Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the healthcare system, government programs and compliance with civil rights laws.
• Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request (which may include written notice to you) or to obtain an order protecting the information requested.
• Law Enforcement: We may release medical information if asked to do so by a law enforcement official:
  • In response to a court order, subpoena, warrant, summons or similar process;
  • To identify or locate a suspect, fugitive, material witness or missing person;
  • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; About a death we believe may be the result of criminal conduct; or
  • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
• Disaster Relief: We may use or disclose your medical information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.
  National Security and Intelligence Activities: We may release medical information about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
• Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.
• Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with healthcare; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
• Reporting Victims of Abuse, Neglect or Domestic Violence: Government authorities that are authorized by law to receive such information, including a social service or protective service agency will be contacted.
• Workers’ Compensation: As authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness, Hometown Health will provide information.
• Data Breach Notification Purposes: We may use your contact information to provide legally-required notices of unauthorized acquisition, access, or disclosure of your health information. We may send notice directly to you or provide notice to delegated entities.
• Additional Restrictions on Use and Disclosure: Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information: HIV/AIDS; Mental health; Genetic tests; Alcohol and drug abuse; Sexually transmitted diseases and reproductive health information; and Child or adult abuse or neglect, including sexual assault.

Medical information of former members of Hometown Health and Senior Care Plus

Senior Care Plus does not destroy the medical information of individuals who terminate their coverage with us. The information is necessary and is used for many purposes described above, even after an individual leaves a plan, and in many cases is subject to legal retention requirements. The practices and procedures that protect that information against inappropriate use or disclosure, however, apply regardless of the status of any individual member.

Your rights regarding medical information about you

You have the following rights regarding medical information we maintain about you:

• Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your healthcare benefits. Usually, this includes benefits, eligibility and claims records, but may not include some mental health information. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Hometown Health Customer Services, 10315 Professional Circle Reno, NV 89521. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed healthcare professional chosen by the health plan will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
• Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Hometown Health. To request an amendment, your request must be made in writing and submitted to Hometown Health Customer Services, 10315 Professional Circle Reno, NV 89521. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
  • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • Is not part of the medical information kept by or for the Hometown Health;
  • Is not part of the information that you would be permitted to inspect and copy; or
  • Is accurate and complete.
• Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you other than (1) our own uses for treatment, payment and healthcare operations, as those functions are described above, (2) to you based upon your authorization and (3) for certain government functions. To request this list or accounting of disclosures, you must submit your request in writing to Hometown Health Customer Services, 10315 Professional Circle Reno, NV 89521. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
• Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose claims information indicating that you have had a surgery. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to Senior Care Plus Customer Services, 10315 Professional Circle Reno, NV 89521. In your request, you 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, disclosures to your spouse).
• Right to Request Confidential Communications: You have the right to request that we communicate with you about healthcare matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Senior Care Plus Customer Services, 10315 Professional Circle Reno, NV 89521. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
• Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice on the Hometown Health website at www.hometownhealth.com. To obtain a paper copy of this notice, please contact Customer Services at 775-982-3112.

Changes to the “Notice of Privacy Practice”

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on the Hometown Health website at www.hometownhealth.com. The notice will contain on the first page, in the top right-hand comer, the effective date. In addition, each time you enroll in a Senior Care Plus Plan, we will offer you a copy of the current notice in effect. We also may publish the current notice in our newsletter on at least an annual basis.

Other uses of medical information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you provide us permission to use or disclose medical information about you by signing an authorization, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Senior Care Plus or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Senior Care Plus, contact Senior Care Plus Customer Services at 775-982-3112 or 888-775-7003 (TTY users call the State Relay Service at 711) from 7 a.m.-8 p.m. PST Monday–Friday. We will provide you with the address to file a complaint with the U.S. Department of Health and Human Services upon request. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

If you have any questions for Senior Care Plus regarding your privacy rights, please call Customer Service at 775-982-3112 or 888-775-7003 (TTY users should call the State Relay Service number at 711) from 7 a.m.-8 p.m. PST Monday-Friday.