Scott & White Health Plan

Notice of Privacy Practices

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.

Please read the Scott & White Privacy Statement to learn how information about visitors to our Web site may be collected and used.

Contacts

If you have questions about this Notice, please call one of the following:
For questions relating to Health Plan Coverage, call SWHP at (254) 298-3000 or (800) 321-7947.
For other questions, call the Scott & White Privacy Office at (254) 724-7600.

Scott and White Health Plan, Insurance Company of Scott and White, and its affiliated entities (collectively SWHP), are committed to safeguarding the confidentiality of your oral, written and electronic personal health information. In order to effectively provide and administer services and benefits to you, SWHP must collect and disclose certain protected health information. This is only done, however, in accordance with SWHP's privacy policies. In addition, Federal law requires that we guard the privacy of your protected health information.

This Notice of Privacy Practices describes how SWHP may collect, use and disclose your protected health information, and your rights concerning your protected health information. Protected health information is information about you or your dependents, including demographic information, that can reasonably be used to identify you and that relates to your past, present, or future physical or mental health or condition, the provision of health care service to you or our payment for that care.

SWHP may use your protected health information internally to perform business activities related to your coverage. When we use your protected health information for such activities, we remove personally identifying data from your protected information when possible, and use only that information necessary to conduct a specific function. We also have in place security procedures to guard your protected health information, and our employees are trained in and agree to comply with our privacy processes when dealing with protected health information.

We are required to safeguard your protected health information and to provide you with this notice about our legal duties and privacy practices. We must follow the privacy practices described in this notice while it is in effect. This notice originally took effect April 14, 2003, was modified on January 1, 2009, and will remain in effect until we replace or modify it.

I. WHAT IS PROTECTED HEALTH INFORMATION (PHI)?

SWHP safeguards the privacy of your protected health information ("PHI"). PHI is information that alone, or in conjunction with other data that we collect from or about you, would allow you to be identified. For example, medical information used to help members get needed care, or information about payments for services you have received, as well as descriptive information about those services, is PHI.

II. HOW WE MAY USE AND DISCLOSE YOUR PHI

In order to provide coverage for treatment and pay for those services, we need to use and disclose your PHI in a number of different ways. The following are examples of the types of uses and disclosures of your PHI that we are permitted to make without your authorization:

• FOR PAYMENT: SWHP will use and disclose your PHI to administer your health benefits policy or contract, which may involve the determination of eligibility; claims payment; utilization review activities; medical necessity review; coordination of benefits and responding to complaints, appeals, and independent review requests. Examples include:
  • Using PHI in order to pay claims that have been submitted to us by physicians and hospitals for payment
  • Transmitting PHI to a third party to facilitate administration of a Flexible Spending Account or Healthcare Reimbursement Account, if you have one
• FOR HEALTH CARE OPERATIONS: SWHP may use and disclose your PHI for operational purposes. For example, your PHI may be disclosed to staff members within SWHP, such as medical-management or quality-improvement personnel, and others to:
  • Assess the quality of care and outcomes in your cases and similar cases
  • Learn how to improve our services and facilities through the use of internal and external surveys
  • Determine how to continuously improve the quality and effectiveness of health care services our members receive
  • Evaluate the performance of our staff, for example, to review our member service representatives' call documentation

In addition, your PHI may be used for the following purposes, each of which is also considered health care operations:

• Sharing of data used for enrollment, disenrollment, and premium billing, as well as summary renewal data with your Plan Sponsor (your employer and/or their representatives, if you are enrolled through an employer group)
  • Other information beyond what is listed above may be shared only after SWHP receives appropriate certifications that the PHI will not be used by your employer for employment decisions or other non-intended purposes.
  • Quality assessment and improvement activities, such as peer review and credentialing of our participating providers.
  • Accreditation by independent organizations such as the National Committee for Quality Assurance.
  • Performance measurement and outcomes assessment, health claims analysis and health services research.
  • Preventive health, early detection, disease management, case management and coordination of care programs, including sending preventive health service reminders.
  • Underwriting, rate making and determining cost-sharing amounts, as well as administration of reinsurance policies.
  • Risk management, auditing and detection of unlawful conduct.
  • Transfer of policies or contracts from and to other insurers, health plans or third party administrators.
  • Other general administrative activities, including data and information systems management, customer service and collecting premiums.
• FOR TREATMENT: SWHP may disclose your PHI to health care providers (doctors, dentists, pharmacies, hospitals and other caregivers) who request it in connection with your treatment. We may also disclose your PHI to health care providers in connection with preventive health initiatives, early detection programs, disease management programs and case management activities. For example, SWHP may disclose information to your primary care physician to suggest a disease management or wellness program that could help improve your health.

  At times, SWHP may contract with other organizations to provide services on our behalf. As these services are performed, PHI is accessed or disclosed. In these cases, SWHP will enter into an agreement explicitly outlining the requirements associated with the protection, use and disclosure of your PHI. An example of such a "business associate" includes behavioral health management companies.

Other permitted or required uses and disclosures of PHI that do not require your authorization include the following:

• PARENTS AS PERSONAL REPRESENTATIVES OF MINORS: In most cases, your minor child's PHI may be disclosed to you. However, we may be required by law to deny a parent's access to a minor's PHI for certain diagnoses or treatment such as sexually transmitted diseases, family planning services, etc.
• WORKERS' COMPENSATION: Your PHI may be used or disclosed in order to comply with laws and regulations related to Workers' Compensation.
• PUBLIC HEALTH ACTIVITIES: Your PHI may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury or disability, tracking of prescription drug or medical device problems, or for other health oversight activities.
• RESEARCH: Under certain circumstances, SWHP may use your PHI for research purposes. All research projects, however, are subject to a special approval process. This special approval process requires an evaluation of the proposed research project and its use of medical information, and balances these research needs with your need for privacy of your PHI. Before we use PHI for research, the project generally will have been approved through this special approval process.
• LEGAL PROCEEDINGS: Your PHI may be disclosed in the course of any legal proceeding, in response to an order of a court or an administrative tribunal and, in certain cases, in response to a subpoena, discovery request or other lawful process.
• IF YOU ARE ENROLLED IN A GROUP HEALTH PLAN: If you are enrolled in SWHP through your work or through a family member's policy, you are enrolled in a "Group Health Plan." If your employer has established procedures to safeguard your PHI as required by federal law, and the Group Health Plan elects to receive PHI from SWHP, we may disclose this information to your sponsoring employer and/or their representative. Talk to your sponsoring employer to get more details.
• HEALTH OVERSIGHT: Your PHI may be disclosed to a government agency authorized to oversee the health care system or government programs or its contractors, [e.g., the U.S. Department of Health and Human Services (HHS), the Texas Department of Insurance or the U.S. Department of Labor] for activities authorized by law, such as audits, examinations, investigations, inspections and licensure activity.
• AS REQUIRED BY LAW: SWHP may use and disclose information about you as required by law. For example, SWHP may disclose information for the following purposes:
  • To report information related to victims of abuse, neglect or domestic violence;
  • To assist law enforcement officials in performing their duties.
• GOVERNMENT FUNCTIONS: Your PHI may be disclosed to prevent serious threat to your health or safety or that of any person pursuant to applicable law. We may also disclose your protected health information to authorized federal officials for national security purposes. In addition, under certain conditions, we may disclose your PHI if you are, or were a member of the Armed Forces, for those activities deemed necessary by appropriate military authorities.
• INMATES: If you are an inmate, your PHI may be disclosed to a correctional institution or a law enforcement official having lawful custody, if the provision of such information is necessary to provide you with health care, protect your health and safety, and that of others, or maintain the safety and security of the correctional institution.
• DECEDENTS: PHI may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties.

• ORGAN/TISSUE DONATION: Your PHI may be used or disclosed to organ procurement organizations to facilitate organ, eye or tissue donation/transplantation.

III. USES AND DISCLOSURES THAT REQUIRE YOUR PRIOR WRITTEN AUTHORIZATION

Uses and disclosures of PHI other than those listed above in Section II will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke such an authorization, at any time in writing, except to the extent that we have already taken an action based on a previously executed authorization.

If a written authorization is obtained from you, your PHI may be disclosed to your personal representative, a person (an adult or an emancipated minor) that SWHP recognizes as having the authority to act on behalf of another individual in making decisions related to health care. Many members ask us to disclose their PHI to third parties for reasons not described in this notice. For example, elderly members often ask us to make their records available to family members or caregivers. To authorize us to disclose any of your PHI to a person or organization for reasons other than those described in this notice, please call the toll free number on your ID card and you will be provided with the appropriate authorization form. You should send the completed form to our Member Services Department. You may revoke the authorization at any time by sending a letter to our Member Services Department at 2401 S. 31st St, Temple, TX 75608.

It is important for you to note that once you give us authorization to release your health information, the PHI that we release is out of SWHP's control. SWHP is unable to safeguard such PHI from redisclosure by the person(s) to whom you have authorized us to release it.

Finally, SWHP will not use your PHI to offer you services or products unrelated to your health care coverage or your health status without your authorization.

IV. YOUR RIGHTS REGARDING YOUR PHI

The following are your rights with respect to your PHI.

Right to access and receive copies of your PHI

You have the right to receive a copy of your PHI. We may ask you to request access to copies of your records in writing and to provide us with the specific information we need to fulfill your request. We reserve the right to charge a reasonable fee for the cost of producing and mailing the copies of such information. There are certain cases in which we are not permitted to fulfill your request to access or receive your PHI.

You may not inspect or copy:

• Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding;
• Psychotherapy notes that may be submitted to SWHP incidental to a member complaint or appeal.
• PHI that is subject to the Clinical Laboratory Improvements Amendments of 1988;
• Information created or obtained by SWHP in the course of research that includes treatment. Access to these records may be temporarily suspended for as long as the research is in progress;
• PHI that was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information.

Right to amend your PHI

If you believe that your protected health information is incorrect or incomplete, you have the right to ask us to amend your PHI. All requests for amendment must be in writing. In certain cases, we may deny your request. For example, we may deny a request if we did not create the information, as is often the case for medical information that is generated by a provider and stored in our records, or if we believe the current information is correct. All denials will be made in writing. You may respond by filing a written statement of disagreement with SWHP and we would have the right to rebut that statement.

If you believe someone has received un-amended PHI from us, you should inform us at the time of the request if you want him or her to be informed of any amendment we may subsequently agree to execute.

Right to request confidential communications

SWHP recognizes that members have the right to receive communications regarding their PHI in a manner and at a location that the individual feels is safe from unauthorized use or disclosure. To support this commitment, SWHP will permit individuals to request that they receive PHI by alternative means or at alternative locations. We will attempt to accommodate reasonable requests. All requests must be in writing.

Right to an accounting of disclosures of PHI

You have the right to request an accounting of those instances in which we have disclosed your PHI for any purpose other than the following:

• For treatment, payment or health care operations;
• To others involved in your health care;
• Disclosures that you or your designated personal representative have authorized;
• Certain other disclosures, such as disclosures for national security purposes;
• Information disclosed to correctional institutions, law enforcement agencies, or health oversight agencies;
• Information that was disclosed or used as part of a limited data set for research, public health or health care operations purposes, and
• Disclosures made prior to April 14, 2003.

All requests must be made in writing. SWHP will require you to provide us with the specific information we need to fulfill your request. If you request this accounting more than once in a twelve-month period, we may charge you a reasonable fee.

Right to request limits on uses and disclosures of your PHI

You have the right to ask us to place restrictions on the way we use or disclose your PHI for treatment, payment or health care operations or as described in the section of this notice entitled "Other Permitted Or Required Uses And Disclosures of PHI." We are not, however, required by law to agree to these requested restrictions. If we do agree to a restriction, we may not use or disclose your PHI in violation of that restriction, unless it is related to an emergency. We may ask that you request these limits in writing.

Right to receive SWHP's Notice of Privacy Practices

You have a right to receive a paper copy of the Notice of Privacy Practices upon request at any time and you may also view a copy of the Notice on our member web site at www.swhp.org.

Rights under state law

You may be entitled to additional rights under state law.

V. HOW TO OBTAIN INFORMATION ABOUT THIS NOTICE OR COMPLAIN ABOUT OUR PRIVACY PRACTICES

To request a copy of this Notice of Privacy Practices at any time, or obtain additional information about this notice, you may contact:

Scott & White Health Plan
2401 S. 31st Street
Temple, Texas 76508
(254) 298-3000, (800) 321-7947

If you believe your privacy rights have been violated, you may file a written complaint with:

Privacy Officer, SWHP, 2401 S. 31st St. Temple, TX 75608 or by contacting this office at 254-298-3000 or 800-321-7947.

You may also notify the Secretary of the Department of Health and Human Services (HHS). SWHP will not take retaliatory action against you if you file a complaint about our privacy practices either with HHS or SWHP.

VI. CHANGES TO THIS NOTICE

We may make a change to this notice and our privacy practices at any time, as long as the change is consistent with our current privacy policies or state or federal law. If we make an important change to our policies, we will promptly provide you with the new notice by mail and post it on our website.

VII. EFFECTIVE DATE OF THIS NOTICE

The effective date of this notice is April 14, 2003, and the first revision became effective on January 1, 2009.