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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.
The United Food and Commercial Workers Unions and Employers Midwest Health Benefits Fund (the "Plan") is required by
law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about:
- the Plan's uses and disclosures of Protected Health Information (PHI);
- your privacy rights with respect to your PHI;
- the Plan's duties with respect to your PHI;
- your right to file a complaint with the Plan and to the Secretary of the U.S. Department of Health and Human
Services; and
- the person or office to contact for further information about the Plan's privacy practices.
The term "Protected Health Information" (PHI) includes all individually identifiable health information transmitted or maintained
by the Plan, regardless of form (oral, written, electronic).
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Section 1. Notice of PHI Uses and Disclosures
Required PHI Uses and Disclosures.
Upon your request, the Plan is required to give you access to your PHI in order to inspect and copy it.
Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to
investigate or determine the Plan's compliance with the privacy regulations.
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Uses and Disclosures to Carry Out Treatment, Payment and Health Care Operations. The Plan and its business
associates will use PHI without your authorization or opportunity to agree or object to carry out treatment, payment and health
care operations. The Plan and its business associates (and any health insurers providing benefits to Plan participants) may
also disclose the following to the Plan's Board of Trustees: (1) PHI for purposes related to Plan administration (payment and
health care operations); (2) summary health information for purposes of health or stop loss insurance underwriting or for
purposes of modifying the Plan; and (3) enrollment information (whether an individual is eligible for benefits under the Plan).
The Trustees have amended the Plan to protect your PHI as required by federal law.
Treatment is the provision, coordination or management of health care and related services. It also includes but is not
limited to consultations and referrals between one or more of your providers. For example, the Plan may disclose to a treating
physician the name of your treating radiologist so that the physician may ask for your X-rays from the treating radiologist.
Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims
processing, subrogation, reviews for medical necessity and appropriateness of care, utilization review and
pre-authorizations). For example, the Plan may tell a doctor whether you are eligible for coverage or what percentage of the
bill will be paid by the Plan.
Health care operations include but are not limited to quality assessment and improvement, reviewing competence or
qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or
renewing insurance contracts. It also includes case management, conducting or arranging for medical review, legal services
and auditing functions including fraud and abuse compliance programs, business planning and development, business
management and general administrative activities. For example, the Plan may use information to project future benefit costs
or audit the accuracy of its claims processing functions.
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Uses and Disclosures that Require Your Written Authorization. The Plan will obtain your authorization before
releasing your PHI in those circumstances where the law or the Plan's privacy practices do not otherwise permit disclosure.
For example, your written authorization generally will be obtained before the Plan will use or disclose psychotherapy notes
about you prepared by your psychotherapist. Psychotherapy notes are separately filed notes about your conversations with
your mental health professional during a counseling session. They do not include summary information about your mental
health treatment.
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Uses and Disclosures that Require that You be Given an Opportunity to Agree or Disagree Prior to the Use or Release.
Disclosure of your PHI to family members, other relatives and your close personal friends is allowed if:
- the information is directly relevant to the family member or friend's involvement with your care or payment for
that care; and
- you have either agreed to the disclosure or have been given an opportunity to object and have not objected.
Additional rules and exceptions apply with family members. You may request additional information from the Plan.
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Uses and Disclosures for Which Your Consent, Authorization or Opportunity to Object is Not Required. The Plan is
allowed to use and disclose your PHI without your authorization under the following circumstances:
- For treatment, payment and health care operations.
- Enrollment information can be provided to the Trustees.
- Summary health information can be provided to the Trustees for the purposes designated above.
- When required by law.
- When permitted for purposes of public health activities, including when necessary to report product defects
and to permit product recalls. PHI may also be disclosed if you have been exposed to a communicable disease or
are at risk of spreading a disease or condition, if required by law.
- When required by law to report information about abuse, neglect or domestic violence to public authorities if there
exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In such case, the Plan will
promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious
harm. For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure
has been or will be made. Disclosure may generally by made to the minor's parents or other representatives although
there may be circumstances under federal or state law when the parents or other representatives may not be given
access to the minor's PHI.
- The Plan may disclose your PHI to a public health oversight agency for oversight activities required by law.
This includes uses or disclosures in civil, administrative or criminal investigations; inspections; licensure or
disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for
appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud).
- The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI may
be disclosed in response to a subpoena or discovery request provided certain conditions are met. One of those
conditions is that satisfactory assurances must be given to the Plan that the requesting party has made a good faith
attempt to provide written notice to you, and the notice provided sufficient information about the proceeding to permit you
to raise an objection and no objections were raised or were resolved in favor of disclosure by the court or tribunal.
- When required for law enforcement purposes, including for the purpose of identifying or locating a suspect,
fugitive, material witness or missing person. Also, when disclosing information about an individual who is or is
suspected to be a victim of a crime but only if the individual agrees to the disclosure or the Plan is unable to obtain
the individual's agreement because of emergency circumstances. Furthermore, the law enforcement official must
represent that the information is not intended to be used against the individual, the immediate law enforcement
activity would be materially and adversely affected by waiting to obtain the individual's agreement and disclosure is
in the best interest of the individual as determined by the exercise of the Plan's best judgement.
- When required to be given to a coroner or medical examiner for the purpose of identifying a deceased person,
determining a cause of death or other duties as authorized by law. Also, disclosure is permitted to funeral directors,
consistent with applicable law, as necessary to carry out their duties with respect to the decedent.
- When consistent with applicable law and standards of ethical conduct if the Plan, in good faith, believes the use or
disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the
public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat.
- When authorized by and to the extent necessary to comply with workers' compensation or other similar
programs established by law.
Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to
your right to revoke such authorization.
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Section 2. Rights of Individuals
Right to Request Restrictions on Uses and Disclosures of PHI. You may request the Plan to restrict the uses and
disclosures of your PHI. However, the Plan is not required to agree to your request. You or your personal representative will
be required to submit a written request to exercise this right. Such requests should be made to the Plan's Privacy Official at
1300 Higgins Road, Suite 300, Park Ridge, IL 60068-5713, 800-621-5133.
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Right to Request Confidential Communications. The Plan will accommodate reasonable requests to receive
communications of PHI by alternative means or at alternative locations if necessary to prevent a disclosure that could
endanger you. You or your personal representative will be required to submit a written request to exercise this right. Such
requests should be made to the Plan's Privacy Official at: 1300 Higgins Road, Suite 300, Park Ridge, IL 60068-5713,
800-621-5133.
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Right to Inspect and Copy PHI. You have a right to inspect and obtain a copy of your PHI contained in a
"designated record set," for as long as the Plan maintains the PHI.
"PHI" includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form.
"Designated record set" includes the medical records and billing records about individuals maintained by or for a
covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management record
systems maintained by or for the Plan; or other information used in whole or in part by or for the Plan to make decisions
about individuals. Information used for quality control or peer review analyses and not used to make decisions about
individuals is not in the designated record set.
You or your personal representative will be required to submit a written request to request access to the PHI in your
designated record set. Such requests should be made to the Plan's Privacy Official at: 1300 Higgins Road, Suite 300,
Park Ridge, IL 60068-5713, 800-621-5133.
The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the
information is maintained off site. A single 30-day extension is allowed if the Plan is unable to comply with the deadline.
If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the
denial, a description of how you may appeal the Plan's decision and a description of how you may complain to the Secretary
of the U.S. Department of Health and Human Services.
The Plan may charge a reasonable, cost-based fee for copying records at your request.
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Right to Amend PHI. You have the right to request the Plan to amend your PHI or a record about you in your
designated record set for as long as the PHI is maintained in the designated record set.
You or your personal representative will be required to submit a written request to request amendment of the PHI in your
designated record set. Such requests should be made to the Plan's Privacy Official at: 1300 Higgins Road, Suite 300,
Park Ridge, IL 60068-5713, 800-621-5133.
The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is
unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial
that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing
with the denial and have that statement included with any future disclosures of your PHI.
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Right to Receive an Accounting of PHI Disclosures. At your request, the Plan will also provide you an accounting of
disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting will not
include PHI disclosures made: (1) to carry out treatment, payment or health care operations (including to business associates
pursuant to a business associate agreement and to the Trustees as authorized by the Plan or the HIPAA privacy regulations);
(2) to individuals about their own PHI; (3) pursuant to your authorization; (4) prior to April 14, 2003; and (5) where otherwise
permissible under the law and the Plan's privacy practices. In addition, the Plan need not account for certain incidental
disclosures.
Such requests should be made to the Plan's Privacy Official at: 1300 Higgins Road, Suite 300, Park Ridge, IL 60068-5713,
800-621-5133.
If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written
statement of the reasons for the delay and the date by which the accounting will be provided.
If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for
each subsequent accounting.
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Right to Receive a Paper Copy of This Notice Upon Request. You have the right to obtain a paper copy of this Notice.
Such requests should be made to the Plan's Privacy Official at: 1300 Higgins Road, Suite 300, Park Ridge, IL 60068-5713,
800-621-5133.
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A Note About Personal Representatives. You may exercise your rights through a personal representative. Your
personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will
be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms:
- a power of attorney for health care purposes, notarized by a notary public;
- a court order of appointment of the person as the conservator or guardian of the individual; or
- an individual who is the parent of an unemancipated minor child may generally act as the child's personal
representative (subject to state law).
The Plan retains discretion to deny access to your PHI by a personal representative to provide protection to those vulnerable
people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect.
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Section 3. The Plan's Duties
The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with
notice of the Plan's legal duties and privacy practices.
This Notice is effective April 14, 2003, and the Plan is required to comply with the terms of this Notice. However, the Plan
reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan
prior to that date. If a privacy practice is changed, a revised version of this Notice will be provided to all participants for
whom the Plan still maintains PHI. The revised Notice will be distributed in the same manner as the initial Notice was provided
or in any other permissible manner.
Any revised version of this Notice will be distributed within 60 days of the effective date of any material change to the Plan's
policies regarding the uses or disclosures of PHI, the individual's privacy rights, the duties of the Plan or other privacy
practices stated in this Notice.
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Minimum Necessary Standard. When using or disclosing PHI or when requesting PHI from another covered entity,
the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to
accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological
limitations.
However, the minimum necessary standard will not apply in the following situations:
- disclosures to or requests by a health care provider for treatment;
- uses or disclosures made to the individual;
- disclosures made to the Secretary of the U.S. Department of Health and Human Services;
- uses or disclosures that are required by law; and
- uses or disclosures that are required for the Plan's compliance with legal regulations.
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De-Identified Information. This notice does not apply to information that has been de-identified. De-identified
information is information that does not identify an individual and with respect to which there is no reasonable basis to believe
that the information can be used to identify an individual.
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Summary Health Information. The Plan may disclose "summary health information" to the Trustees for obtaining
insurance premium bids or modifying, amending or terminating the Plan. "Summary health information" summarizes the claims
history, claims expenses or type of claims experienced by participants and excludes identifying information in accordance
with HIPAA.
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Section 4. Your Right to File a Complaint with the Plan or the HHS Secretary
If you believe that your privacy rights have been violated, you may complain to the Plan. Such complaints should be made to
the Plan's Privacy Official at: 1300 Higgins Road, Suite 300, Park Ridge, IL 60068-5713, 800-621-5133.
You may file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey
Building, 200 Independence Avenue SW, Washington, D.C. 20201.
The Plan will not retaliate against you for filing a complaint.
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Section 5. Whom to Contact at the Plan for More Information
If you have any questions regarding this notice or the subjects addressed in it, you may contact the Plan's Privacy official.
Such questions should be directed to the Plan's Privacy Official at: 1300 Higgins Road, Suite 300, Park Ridge, IL 60068-5713,
800-621-5133.
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Conclusion
PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and
Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to
comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any
discrepancy between the information in this Notice and the regulations.
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