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CCR2006234. . . COMMON COUNCIL - CITY OF MUSKEGO RESOLUTION #234-2006 RESOLUTION TO ADOPT HIPPA COMPLIANCE DOCUMENTS WHEREAS, the City provides for employees a Section 105 plan (for health reimbursement accounts) and a Section 125 plan (for flexible spending accounts), and WHEREAS, the City provides certain health benefits as outlined in Plan documents, and WHEREAS, the City must comply with the Health Portability and Accountability Act (HIPPA) and must, therefore, establish privacy practices related to protected health information. NOW, THEREFORE, BE IT RESOLVED That the Common Council of the City of Muskego, upon the recommendation of the Finance Committee, hereby establishes health information privacy practices as stated in the attached documents titled "City of Muskego Notice of Employee Health Information Privacy Practices." DATED THIS 12th DAY OF December ,2006. SPONSORED BY: FINANCE COMMITTEE Ald. Nancy Salentine Ald. Eileen Madden Ald. Neil Borgman This is to certify that this is a true and accurate copy of Resolution #234-2006 which was adopted by the Common Council of the City of Muskego. 12/06jmb . CITY OF MUSKEGO HUMAN RESOURCES INFORMATION Memo To: Active Employees, Retirees and COBRA Participants in City Health Insurance Plan From: City Administrator Date: Subject: Health Insurance Portability and Accountability Act (HIPPA) Privacy Rules The attached Notice is intended to inform you of practices the City will use to comply with HIPPA privacy rules. Please take note I (Jennifer Sheiffer) am the designated contact for all issues regarding the City's privacy practices and your privacy rights related to the City's administration of the City's health insurance plan. The attached Notice is distributed to inform you of your rights under HIPPA privacy rules. Your health information is kept confidential, not released without authorization, and is not used in any employment decision. This is City policy and as you see in the attached Notice the City now has written privacy practices that will be adhered to. . In summary, these privacy rules include but are not limited to the following: 1. A definition of protected health information. 2. A summary of the permitted uses and disclosures of your protected health information with or without your authorization. 3. Depending upon the request, requirements for your written authorization. 4. Possible requirements that you identify yourself when making a request for your protected health information. 5. Requirements that you identify yourself if you are requesting protected "health information for a family member, and 6. Requirements that you not share medical information about a cO-'Yorker unless that individual authorizes you to do so. If you have any questions regarding this matter, please see/call Jennifer Sheiffer at (262) 679-5589. Thank you. . (11/21/06) . CITY OF MUSKEGO NOTICE OF EMPLOYEE BENEFIT PLAN HEAL TH INFORMATION PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. INTRODUCTION The City of Muskego employee benefit plans ("Plan") provides health benefits (partial reimbursement of deductible costs) to eligible employees and their eligible dependents as described in the City's Summary Plan documents. The Plan creates, receives, uses, maintains, and discloses health information about participating employees and dependents in the administration of health benefit plan. The effective date of this notice is January 1,2007. The Plan is required by law to take reasonable steps to protect from inappropriate disclosure or use any Protected Health Information (PHI) of yours that it maintains. This Plan responsibility excludes the privacy practices of your doctor or other health care provider for the PHI shelhe maintains. Further this notice describes how we may use and disclose your PH] and your rights to access and manage your PHI. As a group health plan we are required by Federal law to maintain the privacy of PHI and to provide you with this notice of our legal duties and privacy practices. Please remember that this is about your privacy and the privacy or your co-workers. Therefore, informal, "lunch room" conversations or casual e-mai]s between employees, about another employee's health, treatment, or health care finances, even out of concern for the employee, are also prohibited under these privacy rules. . 2. PROTECTED HEALTH INFORMATION Your PHI is information that identifies you or could be used to identify you and relates to (I) health care services provided to you, (2) the payment of health care services provided to you, or (3) your physical or mental health or condition. We will abide by the terms of this Notice of Privacy Practices, but reserve the right to change it at any time. Any change in the terms of this Notice will be effective for all PHI that we are maintaining at that time. ]f a change is made to this Notice, a revised Notice will be provided to all individuals covered under the plan at that time. 3. PERMITTED USES AND DISCLOSURES Treatment, Payment and Health Care Operations Federal law allows a group health plan to use and disclose PHI, for the purposes of treatment, payment, and health care operations, without your consent or authorization. Examples of uses and disclosures that we, as a group health plan, may make under each section are listed below: . . Treatment. Treatment refers to the provision and coordination ofhea]th care by a doctor, hospital or the health care provider. As a group health plan we do not provide treatment. . Payment. Payment refers to the activities of a group health plan in collecting premiums and paying claims under the plan for health care services you receive, for example, sending PHI to an external medica] review company to determine the medical necessity or experimental status of a treatment; sharing PHI with other insurers to determine coordination of benefits or to settle subrogation claims; providing PHI to the plan for precertification or case management services; providing PHI in the billing, collection and payment of premiums and fees to plan vendors such as PPO Networks, UR Companies, Prescription Drug Card Companies and reinsurance carriers; and sending PHI to a reinsurance carrier to obtain reimbursement of claims paid under the plan. 1 . · Health Care Operations. Health Care Operations refers to the basic business functions necessary to operate a group health plan, for example, conducting quality assessment studies to evaluate the Plan's performance or the performance ofa particular network or vendor; the use of PHI in determining the cost impact of benefit design changes; the disclosure of PHI to underwriters for the purpose of calculating premium rates and providing reinsurance quotes to the plan; the disclosure of PHI to stop-loss or reinsurance carriers to obtain claim reimbursements to the plan; the disclosure of PHI to plan consultants who provide legal, actuarial and auditing services to the plan; and use of PHI in general data analysis used in the long term management and planning for the plan and the City. Other Uses and Disclosures Allowed Without Authorization Federal law also allows a group health plan to use and disclose PHI, without your consent or authorization, in the following ways. The examples of permitted uses and disclosures listed below are not an all inclusive list of the ways in which PHI may be used. . . To you, as the covered individual. · To a personal representative designated by you to receive PHI or a personal representative designated by law such as the parent or legal guardian of a child, or the surviving family members or representatives of the estate or a deceased individual. · To a Business Associate as part of a contracted agreement to perform services for the Plan. · To a health oversight agency, for example, the Department of Labor, and Internal Revenue Service. · In response to a court order, subpoena, discovery request, audit by the U.S. Department of Health and Human Services (HHS) or other lawful judicial or administrative proceeding. · As required for law enforcement purposes, for example, to notify authorities of a criminal act. · To the Plan Sponsor, as necessary to carry out administrative functions of the plan such as evaluating renewal quotes for reinsurance of the plan, funding check registers, reviewing claim appeals, approving subrogation settlements and evaluating the performance of the Plan. · In providing you with information about treatment alternatives and health services that may be of interest to you as a result of a specific condition that the plan is case managing. · As may be necessary to prevent or lessen a serious and imminent threat to your health, the health and safety of others, or other emergency medical situation. · To comply with workers' compensation laws or other similar programs. 4. OTHER USES AND DISCLOSURES Other uses and disclosures of your PHI will only be made upon receipt of your written authorization. You may revoke an authorization at any time by providing written notice to us that you wish to revoke it. We will honor a request to revoke when it is received and to the extent that we have not already used or disclosed your PHI in good faith under the authorization. 5. YOUR RIGHTS IN RELA nON TO PROTECTED HEALTH INFORMATION Right to Request Restrictions of Uses and Disclosures You have the right to request that the plan limit its uses and disclosures that the Plan makes of your PHI. You also have the right to request the plan restrict the use or disclosure of your PHI to family members or personal representatives. Any such request must be made in writing to the Plan Contact listed in this Notice and must state the specific restriction requested and to whom that restriction would apply. The Plan is not required to agree to a restriction that you request. However, if it does agree to the requested restriction, it may not violate that restriction except as necessary to allow the provision of emergency medical care to you. . Right to Receive Confidential Communications You have the right to request that communications involving PHI be provided to you at an alternative location or by an alternative means of communication. The Plan will accommodate any reasonable request if the normal method of disclosure would endanger you and that danger is generally stated in your request. 2 . Any such request must be made in writing to the Plan Contact listed in this Notice. The Plan will notifY you if it agrees to your request. You should not assume that the Plan has accepted your request until you receive written confirmation. Right of Access to Your Protected Health Information You have the right to inspect and copy your PHI that is contained in the Plan's enrollment, claim adjudication and case management, payment and other records that this plan has created in making claim and coverage decisions relating to you. Federal law prohibits your access to: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding; and PHI that is subject to a law that prohibits access to that information. Right to Amend Protected Health Information You have the right to request that PHI in the Plan's records be amended if you believe that it is incomplete or inaccurate. The plan may deny your request for amendment if it determines that the PHI was not created by the plan, is not part ofthe Plan's records, is not information that is available for inspection, or that the PHI is accurate and complete. If your request for amendment is denied, you have the right to have a statement of disagreement included with the PHI and the plan has a right to include a rebuttal to your statement, a copy of which will be provided to you. Requests for amendment of your PHI must be in writing, including a reason for the amendment, and directed to the Plan Contact listed in this Notice. Right to Receive an Accounting of Disclosures You have the right to receive an accounting of all disclosures of your PHI that the Plan has made, if any, for reasons other than disclosures for treatment, payment and health care operations, as described above, and disclosures made to you or your personal representative. Your right to an accounting of disclosures applies only to PHI created by the plan after the plan's effective date. Requests for an accounting of disclosures of your PHI must be in writing and directed to the Plan Contact listed in this Notice. . Right to Receive a Paper Copy of this Notice You have the right to receive a paper copy of this Notice upon request. This right applies even if you have previously agreed to accept this Notice electronically. Requests for a paper copy of this Notice should be directed to the Plan Contact listed in this Notice. 6. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the Plan Contact listed in this Notice. You will not be retaliated against for filing a complaint. 7. PLAN CONTACT The Plan has designated the following person as a contact for all issues regarding the Plan's privacy practices and your privacy rights. City Administrator City of Muskego Wl82 S8200 Racine Avenue, P.O. Box 749 Muskego, Wisconsin 53 I 50-0749 Phone (262) 679-5589 Fax (262) 679-5630 . (November 21,2006) 3 . . . Authorization to Use or Disclose Protected Health Information To be completed by Individual or Organization requesting release of Protected Health Information (PHI). Patient Name: Social Security Number: Group Name: Group Number: Person/Organization Authorized to Use or Disclose PHI Person/Organization Authorized to Receive PHI Specific Description of Protected Health Information Requested, including dates: The purpose(s) for which you are authorizing use or disclosure of PHI: o My Own Request, or This Authorization will expire on either the following date or upon the occurrence of the following event: To be complet~d by Individual giving Authorization to Use or Disclose Protected Health Information. I hereby authorize the use or disclosure of my protected health information as described above. I understand that this Authorization is voluntary and the PHI to be released may be redisclosed by the recipient and no longer subject to the protection of the Federal Privacy Regulations. I understand that the Plan cannot condition my eligibility for benefits or payment of claims on the signing of this Authorization. I understand that I may revoke this Authorization at any time by notifYing the Person/Organization Authorized to Use or Disclose PHI in writing that I am revoking the Authorization. Such revocation will not affect any use or disclosures made prior to the date they recei ve it. I have read the provisions of this Authorization and understand and agree to its terms. Signature and Printed Name Date If you are Authorized Representative, please indicate relationship or authority to act for individual named at top of Authorization. Your signature certifies & attests that you are the duly authorized personal representative of the individual whose PHI is to be used or disclosed by this Authorization and you have the lawful authority to give the Authorization on behalf of such individual for the following reason (check one): n The individual whose PHI is to be used or disclosed under this Authorization is an unemancipated child and you are the parent, guardian or other person legally acting in the place of a parent; you have the authority under applicable law to make decisions related to the health care for the child; the PHI specified in this Authorization is relevant to your acting as a personal representative; and there is no agreement of confidentiality regarding the requested PHI. n The individual whose PHI is to be used or disclosed under this Authorization is an adult or an emancipated minor, you have authority under applicable law to act on behalf of that individual in making decisions related to health care for that individual and the PHI requested in this Authorization is relevant to your personal representation of that individual. n The individual whose PHI is to be used or disclosed under this Authorization is deceased, you are the executor, administrator or other individual authorized under applicable law to act on behalf of that individual or that individual's estate, and the PHI requested in this Authorization is relevant to your personal representation of that individual or that individual's estate.