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HomeMy WebLinkAbout20030653.tiff RESOLUTION RE: APPROVE ADDENDUM TO MEMORANDUM OF UNDERSTANDING FOR HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA) BUSINESS ASSOCIATE AGREEMENT AND AUTHORIZE CHAIR TO SIGN - CHILD HEALTH ADVOCATES, OPERATED BY POLICY STUDIES, INC. WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with an Addendum to the Memorandum of Understanding for the Health Insurance Portability and Accountability Act (HIPPA) Business Associate Agreement between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and Child Health Advocates, operated by Policy Studies, Inc., commencing March 15, 2003, and ending June 30, 2003, with further terms and conditions being as stated in said addendum, and WHEREAS, after review, the Board deems it advisable to approve said addendum, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Addendum to the Memorandum of Understanding for the Health Insurance Portability and Accountability Act (HIPPA) Business Associate Agreement between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and Child Health Advocates, operated by Policy Studies, Inc., be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said addendum. 2003-0653 HL0030 (0 : NLC=2e RE: ADDENDUM TO MEMORANDUM OF UNDERSTANDING FOR HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA) BUSINESS ASSOCIATE AGREEMENT PAGE 2 The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 12th day of March, A.D., 2003. BOARD OF COUNTY COMMISSIONERS WE COUNTY, COLORADO ATTEST: David E. Long, Chair Weld County Clerk to obi EXCUSED c yt_ ' r, ♦I Robert D. Masden, Pro- em BY: '�� ` co Deputy Clerk to the sty- .11 Ht1 � ' EXCUSED DATE OF SIGNING (AYE) M. J. Geile APPROVE S TO FORM: Willi�� H. Jerky ou ttorney v -- Date of signature: 3' ° Glenn Vaad 2003-0653 HL0030 Addendum to Memorandum of Understanding HIPAA BUSINESS ASSOCIATE AGREEMENT This Addendum ("Addendum") to the Memorandum of Understanding ("MOU") dated , 2003, by and between Child Health Advocates, operated by Policy Studies, Inc. ("PSI/CHA") and (Satellite Eligibility Determination Site hereinafter referred to as "SED Site") is effective as of the compliance date of the Privacy Rule (defined below). RECITALS The parties agree as follows: A. Pursuant to the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA") and regulations promulgated thereunder by the U.S. Department of Health and Human Services (the "HIPAA Regulations") and other applicable laws, as amended, SED Site, through its MOU with PSUCHA, qualifies as a Business Associate of PSI/CHA. B. PSI/CHA wishes to disclose certain information to SED Site pursuant to the terms of the MOU, some of which may constitute Protected Health Information ("PHI")(defined below). C. PSI/CHA and SED Site intend to protect the privacy and provide for the security of PHI disclosed to SED Site pursuant to the MOU in compliance with the HIPAA Regulations. D. As part of the HIPAA Regulations, the Privacy Rule (defined below) requires PSI/CHA to enter into a contract containing specific requirements with SED Site prior to the disclosure of PHI, as set forth in, but not limited to, Title 45, Sections 160.103, 164.502(e) and 164.504(e) of the Code of Federal Regulations ("CFR") and contained in this Addendum. E. Definitions: 1. Except as otherwise defined herein, capitalized terms in this Addendum shall have the definitions set forth in the HIPAA Privacy Rule at 45 C.F.R. Parts 160 and 164, as amended("Privacy Rule"). In the event of any conflict between the mandatory provisions of the Privacy Rule and the provisions of this Addendum, the Privacy Rule shall control. Where the provisions of this Addendum differ from those mandated by the Privacy Rule, but are nonetheless permitted by the Privacy Rule, the provisions of this Addendum shall control. 2. "Protected Health Information" or"PHI" means any information, whether oral or recorded in any form or medium: (i) that relates to the past,present or future physical or mental condition of an individual; the provision of health care to an individual; or the past, present or future 2223-04'53 payment for the provision of health care to an individual; and(ii) that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual, and shall have the meaning given to such term under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.501. 3. "Protected Information" shall mean PHI provided by PSI/CHA to SED Site or created or received by SED Site on PSI/CHA's behalf F. Term. The term of this Addendum begins on the MOU Effective Date, as set forth in the opening paragraph of this MOU, and runs through June 30, 2003. G. Obligations of SED Site. 1. Permitted Uses. SED Site shall not use Protected Information except for the purpose of performing SED Site's obligations under and as permitted by the terms of the MOU. Further, SED Site shall not use Protected Information in any manner that would constitute a violation of the Privacy Rule if so used by PSUCHA. 2. Permitted Disclosures. SED Site shall not disclose Protected Information in any manner that would constitute a violation of the Privacy Rule if disclosed by PSUCHA. 3. Appropriate Safeguards. SED Site shall implement appropriate safeguards as are necessary to prevent the use or disclosure of Protected Information otherwise than as permitted by the MOU. Associate shall maintain a comprehensive written information privacy and security program that includes administrative, technical and physical safeguards appropriate to the size and complexity of the SED Site's operations and the nature and scope of its activities. 4. Reporting of Improper Use or Disclosure. SED Site shall report to PSI/CHA in writing any use or disclosure of Protected Information other • than as provided for by the MOU within five (5)business days of becoming aware of such use or disclosure. 5. SED Site's Agents. If SED Site uses one or more subcontractors or agents to provide services under the MOU, and such subcontractors or agents receive or have access to Protected Information, each subcontractor or agent shall sign an agreement with SED Site containing substantially the same provisions as this Addendum and further identifying PSUCHA as a third party beneficiary with rights of enforcement and indemnification from such subcontractors or agents in the event of any violation of such subcontractor or agent agreement. SED Site shall implement and maintain appropriate sanctions against agents and subcontractors that violate such restrictions and conditions and shall mitigate the effects of any such violation. 6. Access to Protected Information. SED Site shall make Protected Information maintained by SED Site or its agents or subcontractors in Designated Record Sets available to PSUCHA for inspection and copying within ten(10)business days of a request by PSUCHA to enable PSUCHA to fulfill its obligations to permit individual access to PHI under the Privacy Rule, including, but not limited to, 45 C.F.R. Section 164.524. 7. Governmental Access to Records. SED Site shall make its internal practices, books and records relating to the use and disclosure of Protected Information available to the Secretary of the U.S. Department of Health and Human Services (the "Secretary"), in a time and manner designated by the Secretary, for purposes of determining PSI/CHA's compliance with the Privacy Rule. SED Site shall provide to PSI/CHA a copy of any Protected Information that SED Site provides to the Secretary concurrently with providing such Protected Information to the Secretary. 8. Minimum Necessary. SED Site (and its agents or subcontractors) shall only request, use and disclose the minimum amount of Protected Information necessary to accomplish the purpose of the request, use or disclosure, in accordance with the Minimum Necessary requirements of the Privacy Rule including,but not limited to, 45 CFR Sections 164.502(b) and 164.514(d). 9. Data Ownership. SED Site acknowledges that SED Site has no ownership rights with respect to the Protected Information. 10. Retention of Protected Information. SED Site and its subcontractors or agents shall retain all Protected Information throughout the term of the MOU. 11. Notification of Breach. During the term of the MOU, SED Site shall notify PSI/CHA within two (2) business days of any suspected or actual breach of security, intrusion or unauthorized use or disclosure of PHI and/or any actual or suspected use or disclosure of data in violation of any applicable federal or state laws or regulations. SED Site shall take (i)prompt corrective action to cure any such deficiencies and (ii) any action pertaining to such unauthorized disclosure required by applicable federal and state laws and regulations. 12. Audits, Inspection and Enforcement. Within ten (10)business days of a written request by PSI/CHA, SED Site and its agents or subcontractors shall allow PSI/CHA to conduct a reasonable inspection of the facilities, systems, books,records, agreements, policies and procedures relating to the use or disclosure of Protected Information pursuant to the MOU for the purpose of determining whether SED Site has complied with the MOU;provided, however, that: (i) SED Site and PSUCHA shall mutually agree in advance upon the scope, timing and location of such an inspection; (ii) PSUCHA shall protect the confidentiality of all confidential and proprietary information of SED Site to which PSI/CHA has access during the course of such inspection; and (iii) PSUCHA shall execute a nondisclosure agreement, upon terms mutually agreed upon by the parties, if requested by SED Site. The fact that PSUCHA inspects, or fails to inspect, or has the right to inspect, SED Site's facilities, systems, books, records, agreements, policies and procedures does not relieve SED Site of its responsibility to comply with the MOU,nor does PSUCHA's (i) failure to detect or(ii) detection, but failure to notify SED Site or require SED Site's remediation of any unsatisfactory practices, constitute acceptance of such practice or a waiver of PSUCI-JA's enforcement rights under the MOU. 13. Safeguards During Transmission. SED Site shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of Protected Information transmitted to PSUCHA pursuant to the MOU, in accordance with the standards and requirements of the Privacy Rule, until such Protected Information is received by PSUCHA. H. Obligations of PSUCHA. 1. Safeguards During Transmission. PSUCHA shall be responsible for using appropriate safeguards to maintain and ensure the confidentiality, privacy and security of PHI transmitted to SED Site pursuant to the MOU, in accordance with the standards and requirements of the Privacy Rule, until such PHI is received by SED Site. 2. Notice of Changes. PSUCHA shall provide SED Site with a copy of its notice of privacy practices produced in accordance with 45 CFR Section 164.520, as well as any subsequent changes or limitation(s)to such notice,to the extent such changes or limitations may effect SED Site's use or disclosure of Protected Information. PSUCHA shall provide SED Site with any changes in, or revocation of, permission to use or disclose Protected Information, to the extent it may affect SED Site's permitted or required uses or disclosures. To the extent that it may affect SED Site's permitted use or disclosure of PHI, PSUCHA shall notify SED Site of any restriction on the use or disclosure of Protected Information that PSUCHA has agreed to in accordance with 45 CFR Section 164.522. PSUCHA may effectuate any and all such notices of de- identified information via posting on PSUCHA's web site. SED Site shall continually monitor PSI/CHA's designated web site for notice of changes to PSI/CHA's HIPAA privacy policies and practices. Disclaimer. PSUCHA makes no warranty or representation that compliance by SED Site with the MOU, this Addendum, HIPAA or the HIPAA Regulations will be adequate or satisfactory for SED Site's own purposes. SED Site is solely responsible for all decisions made by SED Site regarding the safeguarding of PHI. J. Certification. To the extent that PSUCHA determines an examination is necessary in order to comply with PSUCHA's legal obligations pursuant to HIPAA relating to certification of its security practices,PSUCHA or its authorized agents or contractors, may, at PSI/CHA's expense, examine SED Site's facilities, systems, procedures and records as maybe necessary for such agents or contractors to certify to PSI/CHA the extent to which SED Site's security safeguards comply with HIPAA, the HIPAA Regulations, the MOU or this Addendum. K. Amendment to Comply with Law. The parties acknowledge that state and federal laws relating to data security and privacy are rapidly evolving and that amendment of this Addendum may be required to provide for procedures to ensure compliance with such developments. The parties specifically agree to take such action as is necessary to implement the standards and requirements of HIPAA, the Privacy Rule and other applicable laws relating to the security or privacy of PHI. The parties understand and agree that PSI/CHA must receive satisfactory written assurance from SED Site that SED Site will adequately safeguard all Protected Information. Upon the request of either party, the other party agrees to promptly enter into negotiations concerning the terms of an amendment to this Addendum embodying written assurances consistent with the standards and requirements of HIPAA, the Privacy Rule or other applicable laws. PSI/CHA may terminate the Addendum upon thirty(30) days written notice in the event (i) SED Site does not promptly enter into negotiations to amend this Addendum when requested by PSUCHA pursuant to this Section or(ii) SED Site does not enter into an amendment to this Addendum providing assurances regarding the safeguarding of PHI that PSUCHA, in its sole discretion, deems sufficient to satisfy the standards and requirements of HIPAA and the Privacy Rule. L. Assistance in Litigation or Administrative Proceedings. SED Site shall make itself, and any subcontractors, employees or agents assisting SED Site in the performance of its obligations under this Addendum, available to PSUCHA, at no cost to PSUCHA, to testify as witnesses, or otherwise, in the event of litigation or administrative proceedings being commenced against PSI/CHA, its directors, officers or employees based upon a claimed violation of HIPAA, the Privacy Rule or other laws relating to security and privacy of PHI, except where SED Site or its subcontractor, employee or agent is a named adverse party. M. No Third Party Beneficiaries. Nothing express or implied in this Addendum is intended to confer, nor shall anything herein confer, upon any person other than PSI/CHA, SED Site and their respective successors or assigns, any rights, remedies, obligations or liabilities whatsoever. N. Interpretation. This Addendum shall be interpreted as broadly as necessary to implement and comply with HIPAA and the Privacy Rule. The parties agree that any ambiguity in this Addendum shall be resolved in favor of a meaning that complies and is consistent with HIPAA and the Privacy Rule. O. Audits. In addition to any other audit rights in this Addendum, SED Site shall permit PSI/CHA and any authorized federal agency to monitor and audit records and activities which are or have been undertaken pursuant to this Addendum. P. No Assignment. Except as otherwise provided, the duties and obligations of SED Site shall not be assigned, delegated or subcontracted except with the express prior written consent of PSI/CHA. Any subcontractors or agents used by SED Site to perform any services in connection with this Addendum shall be subject to the requirements of this Addendum. IN WITNESS WHEREOF, the parties hereto have duly executed this Addendum as of the MOU Effective Date. CHILD HEALTH ADVOCATES, SATELLITE ELIGIBILITY Operated by Policy Studies, Inc. DETERMINATION SITE ("PSI/CHA") ("SED SITE") By -"Cf%c4t By L ' SED Site Authorized Person Name: David E. Lon• Title: Chair (03/12/2003 Attest: ro. -` / By Deputy Clerk to the'134a41,-;:#1 -;#, -Wi WELD COUNTY DEPARTMENT OF `\Y PUBLIC HALM Ar,,' ENVIdalriI,,IE Mark E. Wallace, MD. MPH•Director Memorandum vine David E. Long, Chair TO: Board of County Commissioners COLORADO FROM: Mark E. Wallace, MD, MPH, Director Department of Public Health and 7 Environment /J jai DATE: March 10, 2003 ��' SUBJECT: Memorandum of Understanding and Addendum to MOU for CHP+ Satellite Eligibility Determination Site Enclosed for Board review and approval is a Memorandum of Understanding and an addendum to the Memorandum of Understanding for Weld County Department of Public Health and Environment to continue to be a SED (Satellite Eligibility Determination Site) for the Child Health Plan Plus (CHP+). This plan provides for outpatient and inpatient medical services to children under age nineteen in medically indigent families. As a Satellite Eligibility Determination Site, WCDPHE will continue to assist clients in completing their applt"eations for this insurance plan and submit each application with required documentation to the Child Health Advocates. For providing these services, WCDPHE will be paid $10.00 for each completed application submitted within time requirements. The addendum to this MOU states that WCDPHE qualifies as a Business Associate of PSI/CHA (Policy Studies Inc./Child Health Advocates) and both parties agree to protect the privacy and provide for the security of PHI (Protected Health Information) in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The term of this memorandum of understanding and the addendum to it is from March 15, 2003 through June 30, 2001., I recommend your approval of these documents. Enclosure 2003-0653 Hello