May a health plan disclose protected health information to a person who calls the plan on the beneficiary’s behalf?

Answer:

Yes, subject to the conditions set forth in 45 CFR 164.510, links to an external website(b) of the HIPAA Privacy Rule. The Privacy Rule at 45 CFR 164.510(b) permits a health plan (or other covered entity) to disclose to a family member, relative, or close personal friend of the individual, the protected health information (PHI) directly relevant to that person’s involvement with the individual’s care or payment for care. A covered entity also may make these disclosures to persons who are not family members, relatives, or close personal friends of the individual, provided the covered entity has reasonable assurance that the person has been identified by the individual as being involved in his or her care or payment.

A covered entity only may disclose the relevant PHI to these persons if the individual does not object or the covered entity can reasonably infer from the circumstances that the individual does not object to the disclosure; however, when the individual is not present or is incapacitated, the covered entity can make the disclosure if, in the exercise of professional judgment, it believes the disclosure is in the best interests of the individual.

For example:

• A health plan may disclose relevant PHI to a beneficiary’s daughter who has called to assist her hospitalized, elderly mother in resolving a claims or other payment issue.
• A health plan may disclose relevant PHI to a human resources representative who has called the plan with the beneficiary also on the line, or who could turn the phone over to the beneficiary, who could then confirm for the plan that the representative calling is assisting the beneficiary.
• A health plan may disclose relevant PHI to a Congressional office or staffer that has faxed to the plan a letter or e-mail it received from the beneficiary requesting intervention with respect to a health care claim, which assures the plan that the beneficiary has requested the Congressional office’s assistance.
• A Medicare Part D plan may disclose relevant PHI to a staff person with the Centers for Medicare and Medicaid Services (CMS) who contacts the plan to assist an individual regarding the Part D benefit, if the information offered by the CMS staff person about the individual and the individual’s concerns is sufficient to reasonably satisfy the plan that the individual has requested the CMS staff person’s assistance.

Created 3/14/06