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.
Effective
Date April 14, 2003
If you
have any questions about this notice, please contact
The
Missouri State Employees Cafeteria Plan Privacy Officer
PO Box
858.
Columbia
MO 65205-0858
We
create a record of the health care claims made and reimbursed under the Plan
for Plan administration purposes. We also create records regarding your
enrollment in the Plan and premiums you pay to the Plan. This notice applies to all of the medical
records we maintain.
The ways
in which we may use and disclose medical information about you are included in this
notice. It also describes our obligations and your rights regarding the use and
disclosure of medical information. By
law we are required 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 are currently in
effect.
We may
use and disclose medical information about you in the following ways. We have
included some examples as well. Not every use or disclosure in a category is
listed. All of the ways we are
permitted to use and disclose information fall within one of these categories.
For
Payment
We may
use and disclose medical information about you to determine eligibility for Plan
benefits, to facilitate payment for the treatment and services you receive from
health care providers, to determine benefit responsibility under the Plan, or
to coordinate Plan coverage. For
example, we may use medical information to determine if specific services
qualify for payment under the Plan.
For
Health Care Operations
We may
use and disclose medical information about you for other Plan operations. These
uses and disclosures are necessary to run the Plan. For example, we may use
medical information in connection with legal services, audit services, and
fraud and abuse detection programs; business planning and development; and
business management and general Plan administrative activities.
As Required By Law.
We will
disclose medical information about you when required to do so by federal, state
or local law. For example, we may disclose medical information when required by
a court order in a litigation proceeding.
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, the health and safety of someone
else, or the health and safety of the public. Any disclosure, however, would
only be to someone able to help prevent the threat. For example, we may
disclose medical information about you in a proceeding regarding the licensure
of a physician.
Disclosure
to Health Plan Sponsor.
Information
may be disclosed to another health plan maintained by the State of Missouri for
purposes of facilitating claims payments under that plan. In addition, medical
information may be disclosed to designated personnel of the State of Missouri
solely for purposes of administering benefits under the Plan or for enrollment
purposes. We also may disclose summary
health information to the State for the purpose of obtaining bids regarding the
Plan, and modifying or terminating the Plan.
Organ
and Tissue Donation.
If you
are an organ donor, we may release medical information to organizations that
handle organ procurement or organ, eye or tissue transplantation or to an organ
donation bank, as necessary to facilitate organ or tissue donation and
transplantation.
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.
Workers’
Compensation.
We may
release medical information about you for workers’ compensation or similar
programs that provide benefits for work-related injuries or illness.
Public
Health Risks.
We may
disclose medical information about you for public health activities. These
activities generally include the following:
Prevention or control disease, injury or disability;
reporting births and deaths;
reporting child abuse or neglect;
reporting reactions to medications or problems with
products;
notifying people of recalls of products they may be using;
notifying a person who may have been exposed to a disease
or may be at risk for contracting or spreading a disease or condition;
notifying the appropriate government authority if we
believe a person 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 health care system, government programs, and
compliance with civil rights laws.
Lawsuits
and Disputes.
we may
disclose medical information about you in response to a court or administrative
order involving a lawsuit or a dispute in which you are involved. 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 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; and
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.
Coroners,
Medical Examiners and Funeral Directors.
We may
release medical information to a coroner or medical examiner. This may be
necessary, for example, to identify a deceased person or determine the cause of
death. We may also release medical information to funeral directors as
necessary to carry out their duties.
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.
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 health care; (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.
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 Plan benefits. To inspect and copy medical information
that may be used to make decisions about you, you must submit your request in
writing to the Missouri State Employees' Cafeteria Plan Privacy Officer. 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.
Right to Amend.
You may
ask us to amend your medical information if you feel the information we have is
incorrect or incomplete,. You have the right to request an amendment for as
long as the information is kept by or for the Plan. To request an amendment, your request must be made in writing and
submitted to the Missouri State Employees' Cafeteria Plan Privacy Officer. 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:
is not part of the medical information kept by or for the
Plan;
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 information which 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” where such disclosure was
made for any purpose other than treatment, payment, health care operations, or
pursuant to an authorization from you.
You must submit your request in writing to the Missouri State Employees'
Cafeteria Plan Privacy Officer. Your request must state a time period, which
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, paper or electronic). The first list
you request within a 12-month period will be free. We may charge you for the
costs of providing additional lists. We will notify you of the cost involved
and you may choose to withdraw or modify your request 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 health care 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 information about a surgery you had.
We are not required to agree to your request. You must make your request in writing to the Missouri State
Employees' Cafeteria Plan Privacy Officer. 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 medical 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
the Missouri State Employees' Cafeteria Plan Privacy Officer. You will not need
to provide us 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 notices from us
electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our
website, www.mocafe.com. Contact the Missouri State Employees'
Cafeteria Plan Privacy Officer to obtain a paper copy of this notice.
Changes to This Notice
We
reserve the right to change this notice and 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 Plan website. The notice will contain the effective date on the
first page,.
Complaints
If you
believe your privacy rights have been violated, you may file a complaint with
the Plan or with the Secretary of the Department of Health and Human Services.
To file a complaint with the Plan, contact the Missouri State Employees'
Cafeteria Plan Privacy Officer at PO Box 858, Columbia, MO, 65205-0858 or by
email at asi@asiflex.com. All complaints must be submitted in writing. You will not be penalized for filing a
complaint.
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 not be made.
This includes disclosure of information to your spouse or any other
member of your family unless that person has been designated your personal
representative under applicable law and is able to act on your behalf in making
decisions related to health care and such designation has been made to us in
writing.