NOTICE OF PRIVACY PRACTICES
IYC Access Health Plan, Standard Plan, State Maintenance Plan, Medicare Plus
(currently administered by WPS Health Insurance)
Prescription Drug Benefit Plan
(currently administered by Navitus Health Solutions)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. THE PRIVACY OF YOUR INFORMATION IS IMPORTANT TO
US. PLEASE REVIEW IT CAREFULLY.
You do not need to do anything regarding this
notice. It is intended to make you aware of your rights under
the privacy rule of the federal Health Insurance Portability and
Accountability Act (HIPAA) and to inform you how the Wisconsin Department
of Employee Trust Funds (ETF) uses and discloses your protected
health information. Protected health information is information
about you, including demographic data collected from you, that can
reasonably be used to identify you and relates to your past, present
or future physical or mental health or condition, the provision
of health care to you, or the payment for that care.
Please note that while ETF administers many benefit
programs for state and local government employees, this notice applies
to only the plans listed above. Different policies and regulations
apply to records associated with other benefit programs.
ETF receives some protected health information as
a necessary part of administering health benefits for members. ETF and its business associates are required by law to maintain the privacy of your protected health
information and to provide you with a notice of the above plans’
duties and privacy practices and to notify affected individuals following a breach of unsecured protected health information. The term "we" in this notice
means ETF and our business associates. Business associates are companies
and individuals with whom ETF contracts for services, including
but not limited to: claim processing, utilization review, actuarial
services, claim appeals services and participant surveys. In order
to perform their respective functions for ETF, ETF’s business
associates sometimes must receive your protected health information.
ETF requires a contractual commitment from all business associates
to protect the privacy of any health information received in the
course of providing services. The HIPAA Privacy and Security Requirements that apply to ETF also apply to our business associates.
WPS Health Insurance (WPS) is the current third-party
plan administrator for the IYC Access Health Plan, State Maintenance Plan and Medicare Plus.
Navitus Health Solutions (Navitus) is the pharmacy benefit manager
(PBM) for the prescription drug benefit program. WPS and Navitus
are business associates and are required to safeguard your health
information according to HIPAA’s privacy regulation and their
respective contracts with the State of Wisconsin.
If you have health insurance with a health maintenance
organization (HMO) or a preferred provider plan (PPP), you should
receive a notice from your HMO or PPP regarding its privacy practices
relating to your health insurance benefit.
We reserve the right to change the terms of this
notice and to make the new notice provisions apply to information
we already have about you as well as to any information we may receive
in the future. We are required by law to comply with the privacy
notice that is currently in effect. We will notify you of any material
changes to this notice by distributing a new notice to you and posting
the new notice on our web site (http://etf.wi.gov).
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED
Treatment: We may use or disclose
your protected health information for treatment purposes. Treatment
includes providing, coordinating, or managing health care by one
or more health care providers or doctors. Treatment can also include
coordination or management of care between a provider and a third
party, and consultation and referrals between providers. For example,
we may share your health information with a pharmacy in order to
verify your eligibility for benefits.
Payment: We may use or disclose
your protected health information for the payment of covered services
that you receive under your benefit plan or to otherwise manage
your account or benefits. Payment includes activities by ETF or
by organizations hired by ETF to obtain premiums, to make coverage
determinations and to provide reimbursement for health care. This
can include eligibility determinations, reviewing services for medical
necessity or appropriateness, utilization management activities,
claims management, and billing. We may also use and disclose your
protected health information to determine premium costs, underwriting,
rates and cost-sharing amounts. For example, we may share information
about your coverage or the expenses you have incurred with another
health plan in order to coordinate the payment of your benefits. ETF is prohibited from using or disclosing protected health information that is genetic information of an individual for underwriting purposes. ETF will not disclose psychotherapy notes regarding an individual without the individual's authorization except to defend itself in a legal action or other proceeding brought by the individual or as authorized or required by law.
Health Care Operations: We may use
or disclose your protected health information to administer the
plans covered by this notice and to coordinate coverage and services
on your behalf. We may also use or disclose your health information
during the grievance or claim review process in resolving your insurance
complaints. Other examples of health care operations include:
- Quality assessment and improvement activities;
- Activities designed to improve the health plan or reduce costs;
- Reviewing and evaluating health plans, including participant
- Training of ETF personnel and contractors;
- Transfer of eligibility and plan information to business associates
(for example, to the PBM for the management of pharmacy benefits);
- Reviews and auditing, including compliance reviews, ombudsperson
services, legal services, and audit services;
- Business management and general administrative activities,
including customer service; and
- Fraud and abuse detection and compliance programs.
As Permitted or Required By Law: We may share
your protected health information as permitted or required by state
and federal law, including but not limited to disclosures to comply
with Workers’ Compensation laws or similar legal programs;
for U.S. Department of Health and Human Services investigations,
in judicial and administrative proceedings and as required under
Wisconsin law for state auditing purposes.
Organized Health Care Arrangement: We may participate
in an Organized Health Care Arrangement (OHCA). An OHCA can take
several forms under HIPAA, including offering health benefits under
combination of group health plans and HMOs. We may share your protected
health information to coordinate the operations of the plans and
to better serve you as a participant in the plans.
For Distribution of Information Related to Health Benefits
and Services: We may use and disclose your protected health
information to inform you of treatment alternatives or of other
health related services and benefits that may be of interest to
Plan Sponsors: Your employer is not permitted
to receive your protected health information related to the plans
covered by this notice for any purpose other than the administration
and coordination of your benefit plan. For example, we may disclose
to your employer whether an employee is participating in the plans
or has enrolled or disenrolled in any available option offered by
the plans. We may disclose summary health information to your employer,
or someone acting on your employer's behalf, so that it can monitor,
audit or otherwise administer the employee health benefit plan that
the employer sponsors and in which you participate. Summary health
information is data that combines information from many participants
and does not include information on the individual level.
Special Circumstances: If you are unavailable
to communicate, such as in a medical emergency or other situation
in which you are not able to provide permission, we may release
limited information about your general condition or location to
someone who can make decisions on your behalf.
Authorization: We will obtain your
written permission before we use or disclose your protected health
information for any other purpose, unless otherwise stated in this
notice. If you grant such permission,
you may later withdraw your consent at any time, in writing, using
the contact information listed at the end of this notice. We will
then stop using your information for that purpose. However, if we
used or disclosed your information based on your authorization,
we cannot undo any actions we took before you withdrew your permission.
YOUR HEALTH INFORMATION RIGHTS
You have rights under federal privacy laws relating
to your protected health information. If you wish to exercise any
of the following rights, please submit your request in writing to
the ETF Privacy Officer using
the contact information provided at the end of this notice. We are
not required to agree to every request. We will notify you if we
approve your request or explain the reason(s) for our decision if
we deny your
request. We may charge you a fee to cover the costs of processing
your request. If so, we will inform you of the fee before proceeding.
You may request that we not use your protected health information
for certain treatment, payment or health care operations or that
we communicate with you using reasonable alternative means or locations.
View or Receive a Copy of Your Health Information:
You have the right to review or obtain a copy of the protected health
information that is used to make decisions about you. We are not
required to give you certain information, including information
prepared for use in legal actions or proceedings.
Amendment of Your Records: If you
believe that your protected health information is incorrect or incomplete,
you may request that your information be changed. Your request must
include the reason(s) why you believe the change should be made.
In certain situations we will not amend records, such as when we
did not create the records that you want amended.
Request a Listing of Who Was Given Your Information
and Why: Upon request we will provide you with a list of
certain disclosures that we have made since April 14, 2003. The
list will not include disclosures you authorized, or disclosures
we made for treatment, payment, or health care operations or disclosures
for which a listing is otherwise restricted by law.
Copy of the Privacy Notice: You
have a right to obtain a paper copy of this notice at any time.
Complaints: If you feel that your
privacy rights have been violated, you may file a complaint by contacting
ETF’s Privacy Officer using the information provided below.
Federal law prohibits any retaliation against you for filing a complaint.
You may also file a complaint with the federal Office for Civil Rights.
Privacy Rights Contact Information
FAX: (608) 267-0633
|Send written correspondence:
|Department of Employee Trust Funds
P.O. Box 7931
Madison, WI 53707-7931
|Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave.
Chicago, IL 60601
Send secure e-mail correspondence:
access our Internet site and click on the "Email
Revised February 13, 2017