Paloma Health (PH)
Marina Tarasova, HIPAA Privacy Official
(434) 248 7508
Effective Date: October 1, 2019
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.
We understand the importance of privacy and are committed to maintaining the confidentiality of your medical and health information. We maintain records of your health services we cover (claims), and we also maintain information about your health status that we have used for enrollment processing and may receive such records from others. We use these records to administer your health plan benefits and coverage; we may also use these records to coordinate benefits with other health plans, ensure appropriate quality of services provided to you and to enhance the overall quality of our services, and to meet our obligations as a health plan. We consider this health information, and the records we maintain, to be protected health information. We are required by law to maintain the privacy of protected health information and to provide individuals such as health plan participants with notice of our legal duties and privacy practices with respect to protected health information. This notice describes how we may use and disclose your protected health information. It also describes your rights and our legal obligations with respect to your protected health information. If you have any questions about this Notice, please contact our Privacy Official listed above.
We collect health information about you and store it in paper or electronic records formats. This is your health plan record. The health plan record is the property of Paloma Health, but the information in the health plan record belongs to you. The law permits us to use or disclose your health information for the following purposes:
1. Treatment. As a health plan, we may provide information to a health provider who is directly involved in your health care. While this plan does not engage in health care treatment, we may disclose or use your health information to assist in coordinating your care among different providers. Or we may use this information to manage referrals and authorizations for your care with providers, diagnostic facilities, pharmacies and other providers involved in your care.
2. Payment. We use and disclose protected health information about you to adjudicate and pay claims for services rendered to you that are covered by this plan. We may use and disclose information about you to other health plans or third parties to obtain payment when they are also responsible (known as coordination of benefits). We may use and disclose information about you for the purpose of billing and receiving premium payment by your employer, or for the purpose of obtaining reimbursement from a re-insurer of your health plan. We may use and disclose protected health information to work with organizations providing certain specialized benefits. We always take care to ensure that we use or disclose only the minimally necessary protected health information to accomplish these purposes.
3. Health Care Operations. We may use and disclose protected health information about you to operate our health plan. For example, we may use and disclose this information to review and improve the quality of care that is rendered by the health care professionals and providers who treat you. We may use and disclose this information for the purpose of determining your coverage and benefits (commonly known as underwriting and enrollment) and for renewal or changes in your benefits and coverage. We may use or disclose your information for the purpose of improving our benefits and coverage, or to provide disease management services. We may use or disclose information for the purpose of authorizing referrals and services. We may also use and disclose this information as necessary for medical, dental or vision claim reviews, legal services and audits, including fraud and abuse detection, compliance programs and business planning and management. We may also share your protected health information with our "business associates", such as our third party administrator, enrollment processor, reinsurance carrier, and other firms that perform administrative or other services for us. We have a written contract with each of these business associates that contains terms requiring them to protect the confidentiality of your protected health information.
4. Communication. We may communicate with you by mail or by telephone regarding health plan coverage, eligibility questions and coordination of benefits. We will contact you at the home address we have on file for the plan member or the home telephone number on file.
5. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current email address, we may use email to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate.
6. Notification and communication with family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.
7. Disclosures to your employer. We may disclose protected health information about you to the plan sponsor, which is usually your employer, with certain restrictions. We will only disclose whether or not you are enrolled in the health plan and summary health information (which summarizes claims paid and related information but does not identify you or your services). The plan sponsor may use this information to evaluate its sponsorship of the health plan, such as obtaining quotes from other health plans or working with its broker or benefits consultant to modify plan coverage and design. If the plan sponsor requires more than summary or enrollment information, we will only provide that information if the plan documents (your summary plan description or enrollment package) allow this, or are modified to give you notice of this. In any case, the plan sponsor is not allowed to use any such information for employment related decisions about you. Plan sponsors must make certifications to us regarding their uses and disclosures of this information or protected health information and must assure that their agents and subcontractors do the same.
8. Marketing. We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments or health-related benefits and services that may be of interest to you, or to provide you with a list of providers and services covered by the plan. We may also communicate to you about services and products that add value to you but are not necessarily covered benefits. We may also communicate to you about alternative treatment options, alternative settings of care or providers or for case management or improved care such as with disease management. We may communicate with you about a drug or biologic that is currently being prescribed. Our representatives may communicate to you face to face or even provide you a promotional gift of nominal value, for example during a health fair. These activities described above do not require your authorization. For any other marketing activities, including those for which we may receive remuneration, we will not otherwise use or disclose your protected health information without your written authorization. You may also ask to opt out of any marketing communications by notifying the Privacy Official listed above.
9. Required by law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.
10. Public health. We may, and are sometimes required by law to, disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.
11. Health oversight activities. We may, and are sometimes required by law to, disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by applicable law.
12. Judicial and administrative proceedings. We may, and are sometimes required by law to, disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.
13. Law enforcement. We may, and are sometimes required by law to, disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person; complying with a court order, warrant, or grand jury subpoena; and for other law enforcement purposes.
14. Coroners. We may, and are often required by law to, disclose your health information to coroners in connection with their investigations of deaths.
15. Organ or tissue donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.
16. Public safety. We may, and are sometimes required by law to, disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
17. Specialized government functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.
18. Worker’s compensation. We may disclose your health information as necessary to comply with worker’s compensation laws. For example, when a worker’s compensation carrier requests information to coordinate benefits or to determine benefits based on claims we have paid or information we possess.
19. Underwriting Purposes. We may use protected health information to conduct underwriting and underwriting analyses, and for premium rate setting purposes. However, federal law prohibits the use or disclosure of genetic information about an individual for such purposes.
Except as described in this Notice of Privacy Practices, we will not use or disclose health information which identifies you without your written authorization. If you do authorize us to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your health information, by a written request to the Privacy Official specifying what information you want to limit and what limitations on our use or disclosure of that information you wish to have imposed. We reserve the right to accept or reject your request, and will notify you of our decision.
2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing to the Privacy Official, which specify how or where you wish to receive these communications; however you may be required to pay for special communications methods. We may require a statement that all or part of the information we disclose could endanger you.
3. Right to Inspect and Copy. You have the right to inspect and/or copy your health information, with limited exceptions. To access your protected health information, you must submit a written request to the Privacy Official detailing what information you want access to and whether you want to inspect it or get a paper or electronic copy. We will charge a reasonable fee, as allowed by applicable law. We may deny your request under limited circumstances; if we do so, in certain circumstances you have the right to request a review of our denial.
4. Right to Amend or Supplement. You have a right to request that we amend your health information in our possession that you believe is incorrect or incomplete. You must make a request to amend in writing to the Privacy Official, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about our denial of such a request and how you can disagree with the denial. We may deny your request for reasons which include the following: we do not have the information, we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is.
5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by Paloma Health, except that we do not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 17 (specialized government functions) of Section A of this Notice of Privacy Practices, or for disclosures for purposes of research or public health which exclude direct plan participant/member identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent that we have received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.
6. You have a right to a paper copy of this Notice of Privacy Practices, even if you have previously consented to its receipt by e-mail.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Official listed at the top of this Notice of Privacy Practices.
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will provide you with a revised Notice upon a material change to the Notice within 60 days of the material change and revision. We will provide the Notice to you via mail, or via email if you have consented to receive information by email. A copy of the revised Notice is available upon request. We will also post the current notice on our website.
Complaints about this Notice of Privacy Practices or how we handle your health information should be directed to our Privacy Official listed at the top of this Notice of Privacy Practices.
If you are not satisfied with the manner in which Paloma Health handles a complaint, you may submit a formal complaint to the:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Bldg.
Washington, D.C. 20201
You can determine the best method for filing a complaint by visiting www.hhs.gov/ocr including whether to send your complaint to the address above or to your regional Office for Civil Rights.
You will not be penalized or retaliated against in any way by Paloma Health, its employees or business associates if you file a complaint. If you believe you are being retaliated against please immediately contact the Privacy Official listed at the top of this Notice of Privacy Practices.