Each group health plan in which you participate (the "Plan") is required by federal and state law to maintain the privacy of your protected health information ("PHI"). The Plan is also required to give you a Notice which describes its privacy practices, its legal duties and your rights concerning such information and to further notify you of a breach of unsecured PHI. This Notice is the joint Notice for the following health plans sponsored by Woodmen of the World Life Insurance Society ("Plan Sponsor"): the group medical (excluding Medicare eligible retirees and associates residing in Hawaii); dental (excluding all retirees and associates residing in Hawaii), employee assistance plan, employee wellness plan, employee health reimbursement account plan, and the health flexible spending account plan. Retirees (Medicare eligible and dental plans), associates residing in Hawaii (health, dental, vision, prescription drug plans) and participants in the group vision plan will receive a separate Notice covering benefits offered to those individuals.
The Plan is permitted or required to use or disclose your PHI without your authorization (permission) to carry out certain services and activities. Many of those services or activities are performed through contracts with outside persons or organizations, such as auditing, actuarial services, administrative services, legal services, etc. It may be necessary for the Plan to provide certain of your PHI to these outside persons or organizations who assist the Plan with these functions or activities. The Plan requires these persons and entities to appropriately safeguard the privacy of your information.
The Plan is permitted or required to use or disclose your protected health information without your authorization (permission) in any of the following ways:
Treatment. The Plan will make disclosures of PHI as necessary for your treatment. For instance, a doctor or health facility involved in your care may request certain PHI that the Plan maintains in order to make decisions about your care.
Payment. The Plan will use and disclose PHI as necessary for payment purposes. For example, the Plan may use and disclose PHI to pay claims from doctors, hospitals and other providers for services delivered to you that are covered by your health plan, to determine your eligibility for benefits, to determine whether services are medically necessary, to pre-authorize or certify services as covered under your plan of benefits, etc.
Health Care Operations. The Plan will use and disclose PHI as necessary, and as permitted by law, for the Plan's health care operations which include medical review, resolution of appeals, case management, disease management, insurance underwriting, measuring plan and provider performance, audits, legal services, business management and administration, and other similar activities related to your plan of benefits. For example, the Plan may use and disclose PHI to rate its risk and determine premiums, to conduct quality assessment and improvement activities, to engage in care coordination or case management, to manage the Plan's business, etc.
Plan Sponsor. The Plan may disclose PHI to the Plan Sponsor to permit the Plan Sponsor to perform plan administration functions on behalf of the Plan. The Plan documents restrict the uses and disclosures that the Plan Sponsor may make of PHI, and require the Plan Sponsor to certify that the information provided will be maintained in a confidential manner and not used for employment-related decisions or for other employee benefit determinations without your authorization or in any other manner not permitted by law or the Plan documents. For the employee assistance plan, the Plan Sponsor will not receive any PHI without your authorization, except for "summary health information." The Plan may disclose "summary health information" to the Plan Sponsor for obtaining bids or for the purpose of amending or terminating the Plan. "Summary health information" includes claim history, claim expenses and types of claims by individuals without including any personally identifying information. The Plan may also disclose to the Plan Sponsor information on whether you are participating in the Plan.
Information Received Prior to Enrollment. The Plan may receive from you and your health care providers health information prior to your enrollment in the Plan. The Plan will use this information to determine whether you are eligible to enroll in the Plan and to determine your rates. The Plan will not use or further disclose this health information for any other purpose, except as required by law, unless you enroll in the Plan. After enrollment, uses and disclosures are governed by the terms of the Notice then in effect.
Underwriting. The Plan may use and disclose your PHI for underwriting purposes, however, the Plan is prohibited from using or disclosing PHI that is genetic information for such purposes.
Friends and Family. The Plan may disclose PHI to family members or friends who are involved in your care or payment for your care to facilitate that person's involvement in caring for you or paying for your care. If you are present, the Plan will give you the opportunity to object before it makes such disclosures. If you are unavailable, incapacitated or are in an emergency, the Plan may disclose limited information to these persons if the Plan determines disclosure is in your best interest.
Disaster Relief. The Plan may use or disclose your name, location and general condition or death to a public or private organization authorized by law or by its charter to assist in disaster relief efforts.
Deceased Individuals. The Plan may disclose the PHI of a deceased individual to a coroner, medical examiner, or funeral director to carry out their duties as allowed by law.
Organ Donation. If you are an organ donor, the Plan may use or disclose PHI 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.
Research. The Plan may use or disclose PHI for research purposes, in accordance with certain safeguards.
Law Enforcement. The Plan may disclose PHI to law enforcement authorities for law enforcement purposes such as to identify or locate a suspect, fugitive, material witness, or missing person or if you are the victim of a crime.
Public Health Activities. The Plan may disclose PHI for public health activities that are permitted or required by law. These activities may include disclosures to a public health authority to collect or receive such information for the purpose of preventing or controlling disease, injury or disability.
Abuse, Neglect and Domestic Violence. The Plan may disclose PHI to the appropriate government authority if it believes you have been the victim of abuse, neglect or domestic violence.
To Avert a Serious Threat To Health or Safety. Under certain circumstances the Plan may use or disclose PHI if, in good faith, the use or disclosure is necessary to prevent or lessen the threat and is to a person reasonably able to prevent or lessen the threat (including the target) or, under limited circumstances, is necessary for law enforcement authorities to identify or apprehend an individual involved in a crime.
Military and National Security. The Plan may use and disclose PHI if you are a member of the armed forces as required by military command authorities. It may also disclose PHI about foreign military personnel to the appropriate foreign military authority. The Plan may also disclose PHI to federal authorities if necessary for national security or intelligence activities authorized by law.
Legal Proceedings. If you are involved in a lawsuit or a dispute, the Plan may disclose PHI in response to a court or administrative order. The Plan may also disclose PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.
Workers' Compensation. The Plan may disclose PHI to comply with workers' compensation laws or other similar programs providing benefits for work-related injuries.
Health Oversight Activities. The Plan may disclose PHI 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.
Incidental Uses and Disclosures. There are certain incidental uses or disclosures of your PHI that occur while the Plan is conducting its business. We will make reasonable efforts to limit these incidental uses and disclosures.
Required by Law. The Plan will use or disclose PHI when required to do so by federal or state law, including disclosures to the U.S. Department of Health and Human Services upon request for purposes of determining the Plan's compliance with federal law.
Your Authorization. Other uses or disclosures of your PHI not described above will only be made with your written authorization. Such uses and disclosures include, but are not limited to, uses and disclosures of PHI for marketing purposes and disclosures that constitute a sale of PHI. You may also give us written authorization to use your PHI or to disclose it for any other purpose. You may revoke your authorization at any time, but your revocation will not affect any use or disclosure made by the Plan in reliance on your authorization. Without your written authorization, the Plan may not use or disclose your PHI for any reason except those described above.
Notification of Breach. We are required to provide, and you will receive, notification of any breach of your unsecured PHI. We will provide such notification to you without unreasonable delay but in no event later than 60 days after we discover the breach.
Access to Your Protected Health Information. You have the right to copy and/or inspect the PHI that the Plan maintains on your behalf, with limited exceptions. If we maintain the PHI electronically in one or more designated record sets and you ask for an electronic copy, we will provide the information to you in the form and format you request, if it is readily producible in such format. If we cannot readily produce the record in the form and format you request, we will produce it in another readable electronic form we both agree to. All requests for access must be made in writing and signed by you or your personal representative. If you request copies, the Plan may charge you a reasonable, cost-based fee for each page, plus an additional amount for postage if you request a mailed copy. You may also direct us to transmit your PHI to another person, and we will do so, provided your signed, written direction clearly designates the recipient and location for delivery.
Amendment to Your Protected Health Information. You have the right to request in writing that the PHI the Plan maintains about you be amended or corrected. The Plan is not obligated to make all requested amendments but will give each request careful consideration. If the Plan denies your request, you will be provided with a written explanation and an explanation of your rights. All amendment requests must be in writing, signed by you or your personal representative, and must state the reasons for the requested amendment.
Accounting for Disclosures of Your Protected Health Information. You have the right to receive an accounting of certain disclosures made by the Plan of PHI after April 14, 2003. Requests must be made in writing and signed by you or your personal representative. The first accounting in any 12-month period is free; you may be charged a fee for each subsequent accounting you request within the same 12-month period.
Request for Voluntary Restrictions on Use and Disclosure. You have the right to request that the Plan voluntarily place additional restrictions on its use or disclosure of PHI for treatment, payment, health care operations or to persons you identify. The Plan is not required to agree to these additional restrictions, but if it does, it will abide by the agreement (except in an emergency). To be effective, any agreement by the Plan must be in writing signed by a person authorized to make such an agreement on the Plan's behalf. The Plan retains the right to terminate any agreed to restriction upon notification to you of such termination. The termination will only be effective for PHI received after providing notice to you.
Confidential Communications. You have the right to request that the Plan communicate with you about PHI by alternative means or at an alternative location. You must make your request in writing to the address listed at the end of this Notice. The Plan is required to accommodate requests if you inform the Plan that disclosure of all or part of your information could place you in danger, the request is reasonable, specifies the alternative means or location, and continues to permit the Plan to collect premiums and pay claims under your health plan, including issuance of explanation of benefits to the subscriber of the Plan in which you participate.
Complaints. If you have concerns about any of the Plan's privacy practices or believe that your privacy rights may have been violated, you may file a complaint with the Plan. You may also submit a written complaint to the U.S. Department of Health and Human Services by sending a written complaint to the Secretary, Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence SW, Room 509F, HHH Building, Washington, D.C. 20201. The Plan supports your right to protect the privacy of your PHI. Neither the Plan nor the Plan Sponsor will retaliate in any way if you chose to file a complaint with the Plan or with the U.S. Department of Health and Human Services.
Exercising Your Rights. The Plan contracts with outside administrators (the "Administrator") to actually administer and operate the Plan. Under the terms of the arrangement, it is the Administrator, not the Plan, which creates, maintains, and uses most or all the medical information about you. To exercise the individual rights described above or to file a complaint with the Plan contact one or more of the Administrators below. The Administrator(s) will respond to your request on a timely basis as required by law.
Blue Cross and Blue Shield of Nebraska
Attention: Privacy Office
P.O. Box 247040
Omaha, Nebraska 68124-9930
Toll free 1-877-258-3999
MetLife Insurance Company
Institutional Business HIPAA Privacy Office
P.O. Box 6898
Bridgewater, NJ 08807-6896
(908) 253-2706 or HIPAAprivacyinst@MetLife.com
Best Care Employee Assistance Program
9239 West Center Road
Omaha, Nebraska 68124
(402) 354-8000 or toll free 1-800-666-8606
Cypress Benefit Administrators
P.O. Box 7020
Appleton, WI 54912-7020
The Plan is required to abide by the terms of the Notice currently in effect. The Plan reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all of your PHI that it maintains, including that which it created or received while the prior Notice was in effect. If the Plan makes a material change to its privacy practices, it will revise its Notice and provide you with a copy of the revised Notice. If you receive this Notice by electronic mail (e-mail), you are entitled to receive this Notice in written form. Please contact the Benefits Manager at the address listed above to obtain a written copy.
Form 4308 R-10/17