NOTICE OF PRIVACY PRACTICES
OF
FIRSTCAROLINACARE INSURANCE COMPANY, INC.

THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION MAY BE USED AND DISCLOSED AND MEMBER RIGHTS REGARDING THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

Effective: April 14, 2003

For additional information or to make requests, please contact:

Privacy Officer
FirstCarolinaCare Insurance Company, Inc.
42 Memorial Drive
Pinehurst, NC 28374
910-715-8100

A. DUTY TO PROTECT HEALTH INFORMATION

FirstCarolinaCare Insurance Company, Inc. (“FCCICIC”) is required by the federal Health Insurance Portability and Accountability Act (“HIPPA”) to protect the privacy of members’ health information, which is called “protected health information,” or “PHI” for short. FCCIC must give members notice of its legal duties and privacy practices concerning PHI, including:

1.	FCCIC must protect PHI created or received about members' past, present, or future health condition, treatment received, or payment for health care services.
2.	FCCIC must notify members about how it protects their PHI.
3.	FCCIC must explain how, when and why it uses and/or discloses PHI.
4.	FCCIC may only use and/or disclose PHI as described in this Notice

This Notice satisfies items 2 and 3 above, and describes the types of uses and disclosures of PHI that FCCIC may make under the law. In addition, FCCIC may make other uses and disclosures which occur as a byproduct of the permitted uses and disclosures described in this Notice.

FCCIC is required to follow the procedures in this Notice. It reserves the right to change the terms of this Notice and to make new notice provisions effective for all PHI that FCCIC maintains by first:

• Mailing copies of the revised notice to all subscribers; and
• Making copies of the revised notice available upon request through the contact person listed in this Notice.

B. FCCIC MAY USE AND DISCLOSE PHI WITHOUT AUTHORIZATION IN CERTAIN CIRCUMSTANCES.

Except as specifically permitted by law and described below, FCCIC may not disclose to any third party any PHI of a member -- not even to a close relative or spouse – without written authorization of the member.

1. FCCIC may use and disclose PHI so members may receive health care treatment.

FCCIC may use and disclose PHI to provide, coordinate or manage health care and related services. This may include communicating with health care providers when services must be pre-certified by FCCIC, or when verifying eligibility.

EXAMPLE : A doctor treating a member for a broken leg may needs to get enrollment information from FCCIC to determine if the member has health coverage. FCCIC may ask the doctor about the member’s medical condition in order to pre-certify different services that are needed, such as physical therapy, and lab work. FCCIC may also need to disclose PHI to people outside the hospital who may be involved in the member’s medical care after discharge, such as home health providers.

2. FCCIC may use and disclose PHI to make payment for services.

Generally, FCCIC may use and give PHI to others in order to make payment for treatment and services. Such disclosures may be made to:

• Claims processing vendors;
• Hospital or other healthcare facilities;
• Other health plans to determine coordination of benefits; and
• Physicians or other providers of healthcare.

EXAMPLE: If a member has other coverage besides FCCIC, FCCIC may have to send PHI in the form of a claim to the other health plan so that the member can receive all of the benefits to which he/she is entitled.

3. FCCIC may use and disclose PHI for health care operations.

FCCIC may use and disclose PHI in performing its normal business activities, or “health care operations”. Examples of the way FCCIC may use or disclose PHI for “health care operations” include the following:

Reviewing requested services to determine medical necessity;

• Managing and coordinating care more effectively through case management or chronic care management;
• Reviewing and evaluating the skills, qualifications, and performance of network health care providers;
• Cooperating with outside organizations that assess the quality of the care;
• Underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and contracting for reinsurance of risk relating to claims for health care;
• Conducting business management and general administrative activities related to FCCIC and the services it provides, including providing information;
• Resolving member grievances and appeals;
• Complying with this Notice and with applicable laws.

4. FCCIC may use and disclose PHI under other circumstances without authorization.

FCCIC may use and/or disclose PHI in a number of circumstances in which the member’s consent or authorization are not required, and does not otherwise have an opportunity to agree or object. Those circumstances include:

• When the use and/or disclosure is required by law. For example, when a disclosure is required by federal, state or local law or other judicial or administrative proceeding.
• When the use and/or disclosure is necessary for public health activities. For example, FCCIC may disclose PHI if a member has been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
• When the disclosure relates to victims of abuse, neglect or domestic violence.
• When the use and/or disclosure is for health oversight activities. For example, FCCIC may disclose PHI to a state or federal health oversight agency authorized by law to oversee FCCIC operations.
• When the disclosure is for judicial and administrative proceedings. For example, FCCIC may disclose PHI in response to an order of a court or administrative tribunal.
• When the disclosure is for law enforcement purposes. For example, FCCIC may disclose PHI in order to comply with laws that require the reporting of certain types of wounds or other physical injuries.
• When the use and/or disclosure relates to decedents. For example, FCCIC may disclose PHI to a coroner or medical examiner for the purposes of identification.
• When the use and/or disclosure relates to cadaveric organ, eye or tissue donation purposes.
• When the use and/or disclosure relates to medical research.
• When the use and/or disclosure is to avert a serious threat to health or safety.
• When the use and/or disclosure relates to specialized government functions. For example, FCCIC may disclose PHI if it relates to military and veterans’ activities, national security and intelligence activities, protective services for the President, and medical suitability or determinations of the Department of State.
• When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations. For example, in certain circumstances, FCCIC may disclose PHI to a correctional institution having lawful custody of a member.

5. Members can object to certain uses and disclosures.

Unless a member sends a written objection, FCCIC may use or disclose PHI in the following circumstances:

• FCCIC may share with a family member, relative, friend or other specified person PHI directly related to that person’s involvement in the member’s care or payment for care.
• FCCIC may share with a public or private agency (for example, American Red Cross) PHI for disaster relief purposes. Even if the member objects, FCCIC may still share the PHI, if necessary under the emergency circumstances.

If a member would like to object to use or disclosure of PHI in the above circumstances, please call the FCCIC Privacy Officer listed on the first page of this Notice.

6. FCCIC may contact with information about treatment, services, products or health care providers.

FCCIC may use and/or disclose PHI to manage or coordinate health care. This may include telling members about relevant treatments, services, products and/or other healthcare providers, based on PHI in FCCIC’s records.

EXAMPLE: If a member is diagnosed with diabetes, FCCIC may use that information to tell him/her about chronic care management services that may be beneficial.

** ANY OTHER USE OR DISCLOSURE OF PHI REQUIRES WRITTEN AUTHORIZATION **

Under any circumstances other than those listed above, FCCIC will ask for a written authorization before it uses or discloses PHI. If a member signs a written authorization allowing FCCIC to disclose PHI in a specific situation, that authorization can be cancelled in writing. If an authorization is cancelled in writing, FCCIC will not disclose PHI after receiving the cancellation, except for disclosures which were being processed before the cancellation notice was received.

C. MEMBERS HAVE SEVERAL RIGHTS REGARDING THEIR PHI

• Members have the right to request restrictions on uses and disclosures of PHI.

Members have the right to request that FCCIC restrict the use and disclosure of their PHI. The request must be made in writing and sent to the Privacy Officer at the address on the front of this Notice. However, if FCCIC agrees to a request, in certain situations restrictions may not be followed. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in subsection 4 of the previous section of this Notice.

• Members have the right to request that FCCIC communicate with them in certain ways.

Under certain circumstances, members have the right to request how and where FCCIC contacts them about PHI. For example, a member may request to be contacted at a work address or phone number or by email. The request must be in writing and clearly state that disclosure of all or part of that information could endanger the member. FCCIC must accommodate reasonable requests, but, when appropriate, may condition that accommodation on the member providing information regarding how payment, if any, will be handled and specification of an alternative address or other method of contact. Members may request alternative communications by sending a written request to the Privacy Officer at the address on the front of this Notice.

• Members have the right to see and copy their PHI.

Members have the right to request to see and receive a copy of PHI contained in clinical, billing and other records used by FCCIC. The request must be in writing. FCCIC may charge fees for providing copies. Instead of providing a full copy of the PHI, FCCIC may give a summary or explanation of the PHI, if the member agrees in advance to the form and cost of the summary or explanation. There are certain situations in which FCCIC is not required to comply with a request. Under these circumstances, FCCIC will respond in writing, stating why it will not grant the request and describing any rights to request a review of the denial. A member may request to see and receive a copy of PHI by sending a written request to the Privacy Officer at the address on the front of this Notice.

• Members have the right to request amendment of their PHI.

Members have the right to request that FCCIC make amendments to clinical, billing and other records used to make decisions about the member. The request must be in writing and must explain the reason(s) for the amendment. FCCIC may deny the request if: 1) the information was not created by FCCIC (unless the member proves the creator of the information is no longer available to amend the record); 2) the information is not part of the records used to make decisions about the member; 3) FCCIC believes the information is correct and complete; or 4) the member would not have the right to see and copy the record as described in paragraph 3 above.

FCCIC will tell the member in writing the reasons for the denial and describe the rights to give a written statement disagreeing with the denial. If FCCIC accepts a request to amend the information, FCCIC will make reasonable efforts to inform others of the amendment, including persons the member names who have received PHI and who need the amendment. An amendment of PHI may be requested by sending a written request to the Privacy Officer at the address on the front of this Notice.

• Members have the right to a listing of certain disclosures FCCIC has made.

Members have the right to receive a written list of certain of disclosures of their PHI. Members may ask for disclosures made up to six (6) years before their request (not including disclosures made prior to April 14, 2003). FCCIC is required to provide a listing of all disclosures of PHI except those relating to the following:

• For treatment
• For payment for treatment
• For health care operations
• Made to or requested by the member, or that the member authorized
• Occurring as a byproduct of permitted uses and disclosures
• Made to individuals involved in the member’s care, for directory or notification purposes, or for other purposes described in subsection B.5 above
• Allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations (please see subsection B.4 above) and
• As part of a limited set of information which does not contain certain information which would identify the member.

The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure. If, under permitted circumstances, PHI has been disclosed for certain types of research projects, the list may include different types of information.

If a member requests a list of disclosures more than once in 12 months, FCCIC can charge a reasonable fee. Members may request a listing of disclosures by sending a written request to the Privacy Officer at the address on the front of this Notice.

• Members have the right to a copy of this Notice.

Members have the right to request a paper copy of this Notice at any time by sendinga written request to the Privacy Officer. FCCIC will provide a copy of this Notice no later than the date coverage begins.

• MEMBERS MAY FILE A COMPLAINT ABOUT FCCIC PRIVACY PRACTICES.

If a member thinks his/her privacy rights have been violated by FCCIC, or a member wants to make a complaint about FCCIC privacy practices, FCCIC can contact the person listed below:

Privacy Officer
FirstCarolinaCare Insurance Company, Inc.
42 Memorial Drive
Pinehurst, North Carolina 28374
910-715-8100
ryoung@firsthealth.org

Members may also send a written complaint to the United States Secretary of the Department of Health and Human Services.

If a complaint is filed, FCCIC will not take any action against or change its treatment of the member in any way.

EFFECTIVE DATE OF THIS NOTICE

This Notice of Privacy Practices is effective on April 14, 2003.

APPENDIX A

NORTH CAROLINA STATE LAW AND OTHER ISSUES

Some North Carolina state laws provide more protection than the federal law under which this Notice is required. Where applicable, FCCIC will follow the requirements of those state laws. The following North Carolina laws may apply:

• North Carolina law protects the privacy of communications regarding mental health treatment between a patient and a therapist, psychologist or psychiatrist. Before disclosing certain mental health information to others for treatment, payment, or health care operations, FCCIC will request that the member sign a written form giving FCCIC permission to make the disclosure.

There are some exceptions to this requirement. FCCIC can disclose mental health information to members of its workforce, professional advisors and to agencies or individuals which help FCCIC carry out our responsibilities or which oversee operations, or individuals providing emergency medical services to members. FCCIC may also disclose information to other mental health facilities or professionals in order to coordinate care. If FCCIC believes that, based upon information provided to it, there is an immediate danger to the health, safety or welfare of the member or others, or that there is a reason to suspect abuse or neglect of a child or disabled adult, FCCIC may disclose personal information to protect such individual(s). FCCIC may disclose information that would be required in a court proceeding regarding a member’s mental health status, such as a commitment hearing. FCCIC may disclose mental health information to public health authorities if a member has a communicable disease and FCCIC has reason to believe, based upon information provided to it, that there is a public health risk, such as evidence of noncompliance with a treatment plan. FCCIC may provide information to a member’s next of kin, upon request, if the next of kin plays a legitimate role in the member’s therapy; but otherwise, only the fact of admission to or discharge from a mental health facility may be disclosed to the next of kin. In addition, FCCIC is required to provide access to personal information in situations in addition to those required under this Notice.

• Under North Carolina law, minors, with or without the consent of a parent or guardian, have the ability to consent to services for the prevention, diagnosis and treatment of certain illnesses including: venereal disease and other diseases that must be reported to the State; pregnancy; abuse of controlled substances or alcohol; and emotional disturbance. Abortion services, however, still require the consent of the parent, guardian or a grandparent with whom the minor has been living for at least six (6) months unless a court has determined that the minor should be treated as an adult. Minors may petition a court to waive this requirement for parental consent.

• If a member suffers from a communicable disease (for example, tuberculosis, syphilis or HIV/AIDS), information about the disease will be treated as confidential. Other than circumstances described in other sections of this Notice, FCCIC will not release any information about such diseases except as required to protect public health, to prevent the spread of a disease, or at the request of the State or Local Health Director.

• Federal laws generally require written consent before disclosing protected health information related to substance abuse services. There are some exceptions to this requirement. FCCIC can disclose substance abuse information within program to members of our workforce and to agencies or individuals which help FCCIC carry out our responsibilities, or individuals providing emergency medical services. FCCIC may also disclose information to other substance abuse facilities or professionals in order to coordinate care. If there is a reason, based upon information provided to FCCIC, to suspect abuse or neglect of a child, FCCIC may disclose member information to protect such individual(s). FCCIC may disclose information that would be required by a court order. FCCIC may disclose information to communicate with law enforcement personnel about a crime or threatened crime on the premises of a program or against program personnel.