The uses and disclosures that follow are introduced as examples ("including")
Aetna says that in administering your health benefits it may use and disclose personal information in various ways, including the health care operations, payment, treatment and other covered entity disclosures described next. The word "including" shows the list is not stated to be complete here.
Supporting quotations
In administering your health benefits, we may use and disclose personal information about you in various ways, including:
Qualifications & exceptions
Additional reasons, required disclosures, and the authorization rules appear in later sections of the notice.
Use & Processing · Company practice
Health care operations: Aetna may use and disclose information to run its health business
Aetna may use and disclose personal information in running its health business, for example quality assessment and improvement, accreditation, performance measurement, health services research, preventive health, case management and care coordination. It gives nurse case managers as an example. Other operational uses include underwriting and rating, fraud detection and investigation, pharmaceutical program administration and payments where applicable, transfers of policies or contracts between health plans, and general administration such as data systems management and customer service.
Supporting quotations
Health Care Operations: We may use and disclose personal information during the course of running our health business – that is, during operational activities such as quality assessment and improvement; accreditation by independent organizations; performance measurement and outcomes assessment; health services research; preventive health, case management and care coordination.
Other operational activities requiring use and disclosure include underwriting and rating; detection and investigation of fraud; administration of pharmaceutical programs and payments (when applicable); transfer of policies or contracts from and to other health plans; facilitation of a sale, transfer, merger or consolidation of all or part of Aetna Student Health with another entity (including due diligence related to such activity); and other general administrative activities, including data and information systems management, and customer service.
Qualifications & exceptions
Pharmaceutical program administration applies "when applicable."
The operational activities are described with "such as" and "include," so the list is not stated to be exhaustive.
Use & Processing · Company practice
Payment: Aetna may use and disclose information to pay for covered services
To help pay for your covered services, Aetna may use and disclose personal information in conducting utilization and medical necessity reviews, coordinating care, determining eligibility and formulary compliance, collecting premiums, calculating cost-sharing amounts, and responding to complaints, appeals and requests for external review. For example, it may use your medical history to decide whether a treatment is medically necessary and what the payment should be, and may disclose information to your provider during that process.
Supporting quotations
Payment: To help pay for your covered services, we may use and disclose personal information in a number of ways – in conducting utilization and medical necessity reviews; coordinating care; determining eligibility; determining formulary compliance; collecting premiums; calculating cost-sharing amounts; and responding to complaints, appeals and requests for external review.
For example, we may use your medical history and other health information about you to decide whether a particular treatment is medically necessary and what the payment should be – and during the process, we may disclose information to your provider.
Qualifications & exceptions
Introduced as "in a number of ways," so the listed activities are not stated to be exhaustive.
Use & Processing · Company practice
Aetna may use information for treatment alternatives, reminders and other health-related benefits and services
Aetna may use or disclose personal information to provide you with treatment alternatives, treatment reminders, or other health-related benefits and services. It then lists further reasons it may disclose information, covered in the cards that follow.
Supporting quotations
We may use or disclose personal information about you in providing you with treatment alternatives, treatment reminders, or other health-related benefits and services.
We also may disclose such information in support of:
Not stated here
The notice does not say who delivers these alternatives, reminders or services, or whether they can include marketing; it treats marketing unrelated to your benefit plan separately as needing written authorization.
Use & Processing · Company commitment
Aetna asks for your written authorization in all situations other than those described
Aetna says that in all situations other than those described in the notice, it will ask for your written authorization before using or disclosing personal information about you. As examples, it will get authorization for marketing purposes unrelated to your benefit plan, before disclosing psychotherapy notes, for sale of your health information, and for other reasons required by law.
Supporting quotations
In all situations other than those described above, we will ask for your written authorization before using or disclosing personal information about you.
for marketing purposes that are unrelated to your benefit plan(s)
before disclosing any psychotherapy notes
related to the sale of your health information
for other reasons as required by law.
Qualifications & exceptions
The examples are introduced with "for example," so they are not stated to be the only situations requiring authorization.
Not stated here
The notice does not say how Aetna decides marketing is "unrelated to your benefit plan," and treats treatment alternatives and health-related benefits and services as permitted without authorization.
Use & Processing · Company practice
Aetna is not a substance use disorder treatment program but may hold information from one
Aetna says it is not a substance use disorder treatment program, but it may receive or keep information about you that comes from one. If such a program provides the information through a consent under 42 CFR Part 2, including a consent for future uses and disclosures for treatment, payment and health care operations, Aetna says it will use or share the information in accordance with both the consent and HIPAA.
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.
Qualifications & exceptions
Applies where the information arrives through a 42 CFR Part 2 consent.
Not stated here
The notice cites 42 CFR Part 2 without describing it; this card does not explain that law.
Use & Processing · User right or choice
Underwriting: reasons for unfavorable decisions, and genetic information is not used
You have the right to know the reasons for an unfavorable underwriting decision. Previous unfavorable underwriting decisions may not be used as the basis for future underwriting decisions unless Aetna makes an independent evaluation of the basic facts. Your genetic information cannot be used for underwriting purposes.
Supporting quotations
You have the right to know the reasons for an unfavorable underwriting decision. Previous unfavorable underwriting decisions may not be used as the basis for future underwriting decisions unless we make an independent evaluation of the basic facts. Your genetic information cannot be used for underwriting purposes.
Qualifications & exceptions
A prior unfavorable underwriting decision can be a basis for a later one only after an independent evaluation of the basic facts.