Aetna says it may use and disclose personal information while running its health business. The activities named include quality assessment and improvement, licensing, accreditation by independent organizations, performance measurement and outcomes assessment, health services research, and preventive health, disease management, case management and care coordination. For example, it may use information to run disease management programs for members with conditions such as diabetes, asthma or heart failure.
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; licensing; accreditation by independent organizations; performance measurement and outcomes assessment; health services research; and preventive health, disease management, case management and care coordination.
For example, we may use the information to provide disease management programs for members with specific conditions, such as diabetes, asthma, or heart failure.
Qualifications & exceptions
Stated as “may”, not “will”
Listed activities are introduced by “such as”, so the list is illustrative
Later sections say stricter state or federal law can limit the use of certain sensitive information
Not stated here
Which disclosures happen in practice is not stated
Use & Processing · Permission or license
Other operational uses: underwriting, fraud, mergers and sales
Aetna lists further operational activities that require use and disclosure of personal information: reinsurance and stop loss; underwriting and rating; fraud detection and investigation; pharmaceutical programs and payments; transfer of policies or contracts to and from other health plans; facilitating a sale, transfer, merger or consolidation of all or part of Aetna with another entity, including due diligence; and general administration such as data and information systems management and customer service. A later section on your rights says your genetic information cannot be used for underwriting purposes.
Supporting quotations
Other operational activities requiring use and disclosure include administration of reinsurance and stop loss; underwriting and rating; detection and investigation of fraud; administration of pharmaceutical programs and payments; 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 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
Introduced as activities “requiring use and disclosure”
“Including” means the list is not necessarily complete
Genetic information cannot be used for underwriting (rights section)
Not stated here
The passage does not say who receives information in due diligence for a sale or merger or what protections apply there
Use & Processing · Permission or license
Use and disclosure for payment
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, determining 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 and other health information to decide whether a treatment is medically necessary and what the payment should be, and it may disclose information to your provider during that process. It also uses personal information to obtain payment for mail order pharmacy services provided to you.
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.
We also use personal information to obtain payment for any mail order pharmacy services provided to you.
Qualifications & exceptions
The permission is stated as “may”
The mail order pharmacy sentence says “we also use”, a statement of practice rather than a “may”
Later sections say stricter state or federal law can limit the use of certain sensitive information
Use & Processing · Permission or license
Treatment alternatives, reminders and other health-related benefits and services
Aetna says it may use or disclose health information about you in providing you with treatment alternatives, treatment reminders, or other health-related benefits and services.
Supporting quotations
Additional Reasons for Disclosure
We may use or disclose health information about you in providing you with treatment alternatives, treatment reminders, or other health-related benefits and services.
Qualifications & exceptions
Stated as “may”
Applies to health information (the notice’s defined term), not all personal information
Later sections say stricter state or federal law can limit the use of certain sensitive information
Not stated here
Who delivers these alternatives, reminders or services is not stated
Use & Processing · Company commitment
Information from substance use disorder programs
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 a substance use disorder program gives Aetna this information through a 42 CFR Part 2 consent, 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. In limited situations where it may disclose this information without your permission, such as medical emergencies and government audits, Aetna says it will follow the law that is more protective of your information.
Supporting quotations
Substance Use Disorder Information
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
Applies to information that comes from a substance use disorder program under a 42 CFR Part 2 consent
Uses follow both the consent and HIPAA
Where disclosure without permission is possible, the more protective law is followed
Medical emergencies and government audits are given as examples of limited situations
Not stated here
The text refers to 42 CFR Part 2 by citation only; the regulation itself is not supplied
The notice does not say what happens to substance use disorder information that arrives without a Part 2 consent
Use & Processing · User right or choice
Rights about underwriting decisions and genetic information
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.
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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
Prior unfavorable decisions can be relied on only after an independent evaluation of the basic facts
Genetic information cannot be used for underwriting
Not stated here
The notice does not describe how to request the reasons
Cross-references
qualifies (model-proposed): Other operational uses: underwriting, fraud, mergers and sales — qualifies: The statement that genetic information cannot be used for underwriting limits the underwriting and rating activity listed among operational uses.