Aetna may use and share PHI for its health care operations
Aetna may use and share your PHI for its health care operations, which the Notice describes as actions needed to run its health business. The listed examples are quality assessment and improvement, licensing, accreditation by independent organizations, performance measurement and outcomes assessment, health services research, and preventive health, disease and case management, and care coordination. For the last item the Notice gives the example of using your PHI to offer programs for certain conditions, such as diabetes, asthma or heart failure.
Supporting quotations
We may use and share your PHI for our health care operations.
Those are actions we need to do to run our health business, including:
Quality assessment and improvement
Licensing
Accreditation by independent organizations
Performance measurement and outcomes assessment
Health services research
Preventive health, disease and case management, and care coordination
For example, we may use your PHI to offer programs for certain conditions, such as diabetes, asthma, or heart failure.
Qualifications & exceptions
The permission is "may", not a commitment to do each activity.
The list is introduced with "including", so it is not a complete list.
Use & Processing · Permission or license
Other operations include underwriting, fraud investigation, reinsurance and company sale or merger due diligence
Aetna may also use PHI for other operations that require use and disclosure, listed as: administering reinsurance and stop loss; underwriting and rating; investigating fraud; running pharmaceutical programs and payments; moving policies or contracts from and to other health plans; facilitating a sale, transfer, merger or consolidation of all or part of Aetna with another entity, including related due diligence; and performing other general administrative activities, including data and information systems management and customer service. Elsewhere the Notice says Aetna cannot use genetic information to decide whether to issue a policy or for other underwriting purposes.
Supporting quotations
We may also use it for other operations requiring use and disclosure, such as:
Administering reinsurance and stop loss
Underwriting and rating
Investigating fraud
Running pharmaceutical programs and payments
Moving policies or contracts from and to other health plans
Facilitating a sale, transfer, merger or consolidation of all or part of Aetna with another entity (including related due diligence)
Performing other general administrative activities (including data and information systems management and customer service)
Qualifications & exceptions
The list is introduced with "such as", so it is not a complete list.
The rights section says Aetna cannot use genetic information for underwriting purposes.
Use & Processing · Permission or license
Aetna may use and disclose PHI to pay for your covered services
Aetna may use and disclose PHI to help pay for your covered services in activities such as utilization and medical necessity reviews, coordinating care, deciding eligibility, deciding drug list (formulary) compliance, getting premium payments from you, calculating cost-sharing amounts, and responding to complaints, appeals and requests for external reviews. The Notice says these tasks are carried out to make sure Aetna pays for your care the right way.
Supporting quotations
We may use and disclose PHI to help pay for your covered services when:
Doing utilization and medical necessity reviews
Coordinating care
Deciding eligibility
Deciding on drug list (formulary) compliance
Getting premium payments from you
Calculating cost-sharing amounts
Responding to complaints, appeals and requests for external reviews
We carry out these tasks to make sure we pay for your care the right way.
Qualifications & exceptions
The permission is "may" and is tied to payment for covered services.
Use & Processing · Company practice
Aetna may use your health history to decide medical necessity and payment, and share information with your provider
Aetna may use your health history and other PHI to decide whether a treatment is medically necessary and what the payment should be. During this process, it may share information with your health care provider.
Supporting quotations
We may use your health history and other PHI to decide whether a treatment is medically necessary and what the payment should be.
During this process, we may share information with your health care provider.
Qualifications & exceptions
Written as "may".
Use & Processing · Permission or license
Aetna may use or share PHI for treatment alternatives, reminders and health-related benefits and services
Aetna may use or share PHI about you in providing you with treatment alternatives, treatment reminders, or other health-related benefits and services. The same paragraph introduces a list of further disclosures that Aetna may make in support of plan administration, research, business associates, regulation, workers' compensation, law enforcement, legal proceedings, public welfare, legal requirements, decedents and organ procurement.
Supporting quotations
We may use or share PHI about you in providing you with treatment alternatives, treatment reminders, or other health-related benefits and services.
We also may share such information in support of:
Qualifications & exceptions
Written as "may".
Use & Processing · Company commitment
Aetna needs your written okay for uses and disclosures the Notice does not describe
If a use or disclosure is not described in the Notice, Aetna says it will need you to say in writing that it is okay to use or disclose your PHI. Examples where Aetna will get your okay are marketing purposes unrelated to your benefit plan(s), before sharing any psychotherapy notes, when linked to the sale of your PHI, and for other reasons as required by law.
Supporting quotations
If we have not described a use or disclosure above, we will need you to say it’s okay in writing to use or disclose your PHI.
For marketing purposes unrelated to your benefit plan(s)
Before sharing any psychotherapy notes
When linked to the sale of your PHI
For other reasons as required by law
Qualifications & exceptions
Written permission is required for uses and disclosures that were not described.
Marketing needs permission only when it is unrelated to your benefit plans.
The examples are introduced with "For example".
Use & Processing · User right or choice
You can withdraw your written permission any time, in writing
Even if you gave your okay, you can withdraw it at any time by letting Aetna know in writing. If Aetna has not already acted on it, it will stop using or sharing your information for that purpose. You can call the toll-free number on your ID card with questions about written permission.
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Even if you gave us your okay, you can withdraw it anytime.
You just need to let us know in writing.
If we haven’t already acted on it, we’ll stop using or sharing your information for that purpose.
If you have questions about written permission, just call the toll-free number on your ID card.
Qualifications & exceptions
Withdrawal must be in writing.
Aetna stops only if it has not already acted on the permission.
Use & Processing · Company commitment
Aetna may hold substance use disorder program information and follows consent and the more protective law
Aetna says it is not a substance use disorder treatment program but may receive or keep information that comes from one. If a program provides the information through a 42 CFR Part 2 consent, including a consent for future uses and disclosures for treatment, payment and health care operations, Aetna will use or share it in accordance with both the consent and HIPAA. In limited situations where it may disclose this information without your permission, such as medical emergencies and government audits, Aetna will follow the law that is more protective of your information.
Supporting quotations
We are not a substance use disorder treatment program.
We may receive or keep information about you that comes from a substance use disorder program.
If a substance use disorder program provides us this information through a 42 CFR Part 2 consent, including a consent for future uses and disclosures for treatment, payment, and health care operations, we will use or share that information in accordance with both the consent and HIPAA.
In limited situations where we may disclose this information without your permission, such as medical emergencies and government audits, we will follow the law that is more protective of your information.
Qualifications & exceptions
Use follows both the Part 2 consent and HIPAA.
The without-permission examples (medical emergencies, government audits) are introduced with "such as".
Not stated here
The Notice cites 42 CFR Part 2 by name only and does not explain it; the cited rule is not supplied as evidence.
Use & Processing · User right or choice
You can ask Aetna to limit uses and sharing, but it may not agree
You can ask Aetna to limit how it uses or shares your information for health care operations, payment and treatment. Aetna says it will consider, but may not agree to, such requests. The Notice also says you have the right to ask Aetna to restrict sharing with people involved in your health care. Earlier, in the section on sharing with people involved in your care, the Notice says you have the right to stop or limit that kind of sharing. The two passages are worded differently and the Notice does not say whether Aetna may refuse a request to restrict sharing with people involved in your care.
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Ask us to limit the way we use or share your information when it comes to health care operations, payment and treatment.
We will consider, but may not agree to, such requests.
You also have the right to ask us to restrict sharing with people involved in your health care.
You have the right to stop or limit this kind of sharing (disclosure).
Qualifications & exceptions
For health care operations, payment and treatment, Aetna may decline the request.
Whether the "may not agree" sentence also applies to restricting sharing with people involved in your care is not stated.
Not stated here
The earlier section says you have the right to "stop or limit" sharing with people involved in your care; this section says you may "ask" to restrict it; the Notice does not reconcile the wording.
Use & Processing · User right or choice
You can know reasons for a denial, and Aetna cannot use past denials or genetic information in underwriting
You have the right to know the reasons for denying an insurance policy or another unfavorable underwriting decision. If you were denied a policy in the past, Aetna says it cannot use that information in its decision process and must review the facts on its own. Aetna also says it cannot use your genetic information to decide whether to issue you a policy or for other underwriting purposes.
Supporting quotations
Know the reasons for denying an insurance policy or other unfavorable underwriting decision.
If you’ve been denied a policy in the past, we can’t use that information in our decision process.
We must review the facts on our own.
Also, we can’t use your genetic information to decide if we should issue you a policy or for other underwriting purposes.
Qualifications & exceptions
The genetic-information limit covers deciding whether to issue a policy and other underwriting purposes.