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  • Member Policies and Rights > Member Rights

    The protection and security of our members' personal information is a major objective of EmblemHealth. Our Notice of Privacy Practices describes how medical information about our members may be used and disclosed and how our members can get access to this information. Our member handbook tells members how to give consent to the collection, use and release of personal health information, how to obtain access to their medical records and what we do to protect access to their personal information. We are also committed to serving our members in a culturally competent and nondiscriminatory manner.

    Confidentiality of Personal Information

    As members consider joining an EmblemHealth plan, we want them to know that we make the protection of personal information a high priority. Our members entrust us with information that is personal, sensitive and highly confidential. Our employees and other authorized individuals working for us are accountable for exercising a high degree of care in safeguarding the confidentiality of that information.

    Indeed, our employees and other authorized individuals are prohibited from:

    • Accessing or trying to access personal information, except on a "need to know" basis and only when authorized to do so.
    • Disclosing personal information to any person or organization within or outside the Plan, unless that person or organization has a "need to know" and is authorized by us to receive that information.

    Confidentiality of Health Information for Minors Enrolled in Medicaid Managed Care Plans

    Effective September 1, 2016, EmblemHealth will suppress all Explanation of Benefits (EOBs) for Medicaid minors 0 – under 18 years of age, with the exception of dental-related services and situations where the member may be financially responsible. New York State Department of Health (DOH) requires Medicaid Managed Care Plans, including EmblemHealth, to establish an effective, uniform and systemic mechanism to comply with confidentiality protections for health care services provided to minors who are enabled by statute to consent to their own heath care.

    Member Consent

    Providers should be aware of who may and may not consent for care. Public Health Law section 2504 specifically states the following:

    • Any person who is 18 years of age or older, or is the parent of a child or has married, may give effective consent for medical, dental, health and hospital services for himself or herself, and the consent of no other person is necessary.
    • Any person who has been married or who has borne a child may give effective consent for medical, dental, health and hospital services for his or her child. Any person who has been designated by law as a person in parental relation to a child may consent to any medical, dental, health and hospital services for such child for which consent is otherwise required. The above excludes (a) major medical treatment as defined in the mental hygiene law; (b) electroconvulsive therapy; and (c) the withdrawal or discontinuance of medical treatment that is sustaining life functions.
    • Any person who is pregnant may give effective consent for medical, dental, health and hospital services relating to prenatal care.
    • Medical, dental, health and hospital services may be rendered to persons of any age without the consent of a parent or legal guardian when, in the physician's judgment an emergency exists and the person is in immediate need of medical attention and an attempt to secure consent would result in a delay of treatment that would increase the risk to the person's life or health.
    • Where not otherwise already authorized by law to do so, any person in a parental relation to a child as defined by law as well as (i) a grandparent, an adult brother or sister, or an adult aunt or uncle, any of whom has assumed care of the child and (ii) an adult who has care of the child and has written authorization to consent from a person in a parental relation to a child as defined by law may give effective consent for the immunization of a child. However, a person other than one in a parental relation to the child cannot give consent under this subdivision if he or she has reason to believe that a person in parental relation to the child (as defined by law) objects to the immunization.
    • Anyone who acts in good faith based on the representation by a person that he or she is eligible to consent pursuant to the terms of this section shall be deemed to have received effective consent.

    Health Insurance Portability and Accountability Act (HIPAA)

    HIPAA requires providers to take reasonable and appropriate measures to protect member/patient information. Examples of measures considered reasonable and appropriate to safeguard the patient chart include limiting access to certain areas, ensuring that the area is supervised, escorting non-employees in the area, and placing the patient chart in the box with the front cover facing the wall so that protected health information is not visible to anyone who walks by. An office sign-in sheet may not display medical information that is unnecessary for the purpose of signing in (e.g., information about symptoms or treatment). In addition, while providers may leave messages for members on home answering machines, they should consider leaving only the member's name on the machine along with information necessary to confirm an appointment, or simply asking the individual to call back.

    Confidentiality of HIV-related Information

    The provider must develop policies and procedures to assure confidentiality of HIV-related information. These policies and procedures must include:

    • Initial and annual in-service education of staff and contractors
    • Identification of staff allowed access and limits of access
    • Procedures to limit access to trained staff (including contractors)
    • Protocols for secure storage (including electronic storage)
    • Procedures for handling requests for HIV-related information
    • Protocols to protect persons with or suspected of having HIV infection from discrimination

    Confidentiality of Behavioral Health and Substance Use Information

    Each provider must develop policies and procedures to assure confidentiality of mental health and substance related information. These policies and procedures must include:

    • Initial and annual in-service education of staff and contractors
    • Identification of staff allowed access and limits of access
    • Procedures to limit access to trained staff (including contractors)
    • Protocols for secure storage (including electronic storage)
    • Procedures for handling requests for BH/SU information protocols to protect persons with behavioral health and/or substance use disorder from discrimination

    Routine Consent

    Before releasing personal information, consent must first be obtained from the member or a qualified person, unless release of that information is required by law. In many cases, when new members enroll in an EmblemHealth plan, routine consent for release of information is obtained on the enrollment application. The consent authorizes the use of personal information for general treatment, coordination of care, quality assessment, utilization review and fraud detection. The consent also authorizes the use of personal information for oversight reviews, such as those performed by the state or for accreditation purposes. In addition, it covers future routine use of such information. HIPAA permits the disclosure of information for payment, treatment and health care operations.

    Authorization to Release Information

    Authorization must be obtained from the member or qualified person before any personal health information can be released to an outside organization or agency, unless release of that information is legally required or permitted.

    Special restrictions apply to the release of information relating to alcohol and drug abuse, abortion, sexually transmitted disease, adoption, psychiatric treatment, psychotherapy notes and HIV/AIDS.

    Access to Medical Records

    Our providers maintain medical records for the benefit of our members. A member has the right to review, copy and request amendments to his or her medical record. Any member or qualified person who desires a copy of the medical record may obtain one by submitting a written request to his or her network or facility.

    A member or qualified person may challenge the accuracy of the information in the medical record. In addition, he or she may require that a statement describing the challenge be added to the record.

    Access by a member or qualified person to information in the medical record may be denied, but only if the network provider or facility determines that:

    • Access can reasonably be expected to cause substantial harm to the member or to others
    • Access would have a detrimental effect on the network practitioner's or facility's professional relationship with the member, or on their ability to provide treatment

    Nondiscrimination

    The network provider represents and warrants to EmblemHealth that he or she will not discriminate against members with respect to the availability or provision of health services based on a member’s race, ethnicity, creed, sex, age, national origin, religion, place of residence, HIV status, source of payment, plan membership, color, sexual orientation, marital status, veteran status, or any factor related to a member’s health status, including, but not limited to, a member’s mental or physical disability or medical condition or handicap or other disability, claims experience, receipt of health care, medical history, genetic information or type of illness or condition, evidence of insurability (including conditions arising out of acts of domestic violence), disability or on any other basis otherwise prohibited by state or federal law.

    Further, the provider shall comply with Title VI of the Civil Rights Act of 1964, as implemented by regulations at 45 C.F.R. part 84; the Americans with Disabilities Act; the Age Discrimination Act of 1975, as implemented by regulations at 45 C.F.R. part 91; other laws applicable to recipients of federal funds; and all other applicable laws and rules, as required by applicable laws or regulations. The provider shall not discriminate against a member based on whether or not the member has executed an advance directive. The provider acknowledges that EmblemHealth is receiving federal funds and that payments to the provider for covered services are in whole or in part from federal funds.

    Cultural Competency

    The US Department of Health & Human Services defines cultural and linguistic competence as a set of congruent behaviors, attitudes and policies that come together in a system or agency or among professionals and enable effective work in cross-cultural situations. Delivering quality, sensitive care to a diverse cross-cultural population promotes respectful and responsive health care without cultural communication differences hindering the relationship.

    For additional information regarding cultural and linguistic competence, as well as educational materials and online courses, the following resources are available:

    • US Department of Health & Human Services: The Office of Minority Health
    • AHRQ: Setting the Agenda for Research on Cultural Competence in Health Care
    • America’s Health Insurance Plans: Tools to Address Disparities in Health
    • EmblemHealth Learn Online: Cultural Competency

    In addition, EmblemHealth encourages its providers (medical, physical, behavioral, long term services and support [LTSS] and pharmacy) to consider how people’s religious beliefs and practices intersect with medical science. We recognize that cultural competence is particularly important to the diverse cultural and religious identities of our members and the communities we serve.

    That is why we sponsored Tanenbaum Center for Interreligious Understanding to write The Medical Manual for Religio-Cultural Competency. It is user-friendly and filled with information for the busy health care practitioner who wants to be religio-culturally competent. Its wide-ranging chapters not only include practical information on the various religions, but also spiritual assessment forms and tools and tips for working effectively with people of diverse religious backgrounds and points of view. As a leader in providing coverage of innovative and evidence-based approaches to health care, EmblemHealth is pleased to offer this first-of-its-kind publication to our network practitioners. Log on to emblemhealth.com to access The Medical Manual.

    Notice of Privacy Practices

    See the following page for our Notice of Privacy Practices.

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    Glossary terms found on this page:

    An evaluative process in which a health care organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    A business entity that performs delegated functions on behalf of the insurer or managed care organization.

    A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

    Understanding the values, beliefs and needs associated with an individual’s age, gender identity, sexual orientation, and/or racial, ethnic or religious background. Cultural competence also includes a set of competencies required to ensure appropriate, culturally sensitive health care to persons with congenital or acquired disabilities.

    Medical equipment, goods, implements and prosthetics that are prescribed for patient care, usually in an outpatient setting. Examples of such equipment include hospital beds, wheelchairs and walkers.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called Explanation of Benefits.

    A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called an EOB.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as HIPAA.

    A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as the Health Insurance Portability and Accountability Act.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

    The state regulatory agency that certifies reimbursement methods and rates to hospitals and reviews HMO activities in the state of New York. Also called NYSDOH.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.

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