HIPAA

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HIPAA

• Continuing Education Course
• Sponsored by UNICARE
• Course 32141CL010

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HIPAA

• Background
• Recent Changes - Privacy legislation
• General Provisions
• Small Group Provisions
• Individual Provisions
• Miscellaneous Provisions
• MSAs

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Background

• On August 21, 1996, President Clinton signed
  into law the Health Insurance Portability and
• Accountability Act of 1996. This law includes
  important new protections for millions of working
  Americans and their families who have preexisting
  medical conditions or might suffer discrimination
  in health coverage based on a factor that related
  to an individuals health.

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Background

• HIPAA provisions amend Title I of the Employee
• Retirement Income Security Act of 1974 (ERISA)
• as well as the Internal Revenue Code and the
• Public Health Service Act. It also places
• requirements on employer-sponsored group
• health plans, insurance companies and health
• maintenance organizations (HMOs).

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States Can Modify Portability Requirements by

• Shortening 6-month look-back period prior to
  enrollment date to determine what is a
  preexisting condition
• Shortening the 12- and 18-month maximum
  preexisting condition exclusion periods
• Increasing the 30-day period in which to enroll
  newborns and adopted/adoption children to avoid
  preexisting condition exclusion

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States Can Modify Portability Requirements by

• Expanding the prohibitions on conditions people
  to whom a preexisting condition exclusion period
  may be applied beyond the exceptions described
  in federal law
• Requiring additional special enrollment periods
• Reducing maximum HMO affiliation period to less
  than 2 months (3 months for late enrollees)

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New Privacy Legislation
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Privacy Legislation

• Outline specific rights for individuals regarding
  protected health information
• Obligations of healthcare providers, health
  plans, and health care clearinghouses
• Grant healthcare consumers a greater level of
  control over the use and disclosure of personally
  identifiable health information

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Privacy Legislation

• Healthcare providers, health plans, and
• clearinghouses are prohibited from using or
• disclosing health information except as
• authorized by the patient or specifically
• permitted by the regulation.

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Privacy Legislation

• The final rules applicability is expanded to
• include all personally identifiable health
• information, irrespective of form. There is
• no longer an exclusion for written medical
  records never transferred to electronic form or
  oral communications.

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Privacy Legislation

• Direct healthcare providers must obtain written
  consent from a patient for use and disclosure of
  health information
• Even if the use or disclosure is related such
  routine purposes as treatment or payment
• A separate, specific authorization is required
  for non-routine disclosures
• Patients are granted the opportunity to request
  restrictions on the use and disclosure of their
  health information

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Privacy Legislation

• Within 60 days of a request, patients are
• entitled to a disclosure history identifying all
• entities that received health information
• unrelated to treatment or payment.

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Privacy Legislation

• Patients also have a right to review and copy
• their own medical records and have the
• corresponding right to request amendments or
• corrections to potentially harmful errors
• within the record.

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HIPAA Changes Include

• Limit exclusions for preexisting conditions
• Prohibit discrimination against employees and
  dependents based on their health status
• Guarantee renewability and availability of health
  coverage to certain employers and individuals
• Protect many workers who lose health coverage by
  providing better access to individual health
  insurance coverage

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Eligibility

• Must have most recent coverage under a group
  health plan
• Must have 18 months of creditable coverage under
  one or more health plans
• Not eligible if eligible for coverage under a
  group health plan, or for Medicare or Medicaid
• Must have enrolled in and exhausted COBRA
  benefits, if available

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Preexisting Condition Exclusions

• Must relate to a condition for which medical
  advice, diagnosis, care or treatment was
  recommended or received during the 6-month period
  prior to an individuals enrollment date
• May not last for more than 12 months (18 months
  for late enrollees) after an individuals
  enrollment date

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Preexisting Condition Exclusions

• The 12- (or 18-) month period must be reduced by
  the number of days of the individuals prior
  creditable coverage (excluding coverage before
  any break in coverage of 63 days or more)
• The period of any preexisting condition
  exclusion that would apply under a group health
  plan is generally reduced by the number of days
  of creditable coverage

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Preexisting Condition Exclusions

• Issuers may impose preexisting condition
• waiting periods on dependents who are not
• eligible individuals.

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Exceptions to Preexisting Conditions

• However, carriers may not apply a preexisting
• condition exclusion to pregnancy, newborns, or
• newly adopted children who were covered within
• 30 days of birth or adoption/placement for
• adoption, and have not had a significant break in
  
• coverage of 63 days or more.

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Enforcement

• States have primary responsibility to enforce
  these protections
• If states fail to act, the Secretary of Health
  Human Services can enforce, including imposing
  civil monetary penalties on insurers

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Enforcement

• The Secretary of labor will enforce these rules
  for self-insured (ERISA) plans
• The tax code is modified to allow the Secretary
  of Treasury to impose tax penalties on employers
  or insurance plans that are out of compliance

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Information Health Plans Must Provide to
Participants and Beneficiaries
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Information to Provide to Participants
Beneficiaries

• The Secretary of Labor enforces the health care
  
• portability requirements on group health plans
• under ERISA, including self-insured
• arrangements. In addition, participants and
• beneficiaries can file suit to enforce their
  rights
• under ERISA, as amended by HIPAA.

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Information to Provide to Participants
Beneficiaries

• Carriers must notify participants and
  beneficiaries of material reductions in covered
  services or benefits, generally within 60 days
  of adoption of the change.

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Information to Provide to Participants
Beneficiaries

• Disclose to participants and beneficiaries
• information about the role of issuers with
  respect
• to their health plan - name, address of issuer,
• what benefits under the plan are guaranteed
• under a contract or policy of insurance, and the
• nature of any administrative services.

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• Material reduction in covered services or
• benefits includes any plan modification or
• change that
• Eliminates benefits payable under the plan
• Reduces benefits payable under the plan,
  including a reduction that occurs as a result of
  a change in formulas, methodologies or schedules
  that serve as the basis for making benefit
  determinations

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• Material reduction in covered services or
• benefits includes any plan modification or
• change that
• Increases deductibles, co-payments or other
  amounts to be paid by a participant or
  beneficiary
• Reduces the service area covered by a health
  maintenance organization
• Establishes new conditions or requirements to
  obtain services or benefits under the plan
  (e.g., preauthorization requirements)

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Product Termination

• The insurer must
• Provide notice to each covered individual 90 days
  before the date coverage is discontinued
• Offer individuals whose policies will not be
  renewed the opportunity to enroll in any other
  coverage that it offers to individuals
• Discontinue coverage uniformly and without
  considering the health status of policy holders

29
Market Exit

• The insurer must provide notice to each covered
  individual 180 days before the date coverage is
  discontinued
• Must discontinue and not renew any coverage that
  it offers to individuals
• Insurer may not reenter the market for five years

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Group Coverage Provisions
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Creditable Coverage

• A group health plan (including COBRA)
• HMO
• Individual health insurance policy
• Medicaid Medicare
• Note Creditable coverage does not include
  coverage consisting solely of excepted benefits
  such as stand-alone dental or vision benefits

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Creditable Coverage

• Group health plans and issuers were not required
  to provide certificates before June 1, 1997.
  Generally, the certification requirements apply
  to periods of coverage that occur after June 30,
  1996 and certificates must be provided when
  coverage ceases under the plan. After June 1,
  1997, plans or issuers must provide certificates
  to individuals as they lose coverage or begin
  COBRA.

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Certificate of Creditable Coverage

• Must be provided by the plan or issuer when a
  individual either loses coverage under the plan
  or becomes entitled to COBRA
• Must also be provided, if requested, before the
  individual loses coverage or within 24 months of
  losing coverage
• May be provided through the use of the model
  certificate available from the Department of Labor

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Nondiscrimination Requirements

• Group health plans and issuers may not
• establish rules for eligibility of any individual
  
• to enroll under the terms of the plan based on
• health status-related factors.

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These Factors are

• Health status
• Medical condition - physical or mental
• Claims experience
• Receipt of health care
• Medical history
• Genetic information
• Evidence of insurability or disability

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Implementation

• As of June 30, 1997, group health plans must
  comply with all nondiscrimination, preexisting
  condition and crediting of prior health coverage
  requirements at the beginning of the first plan
  year starting after June 30, 1997.
• Health insurance coverage without a significant
  break that you have after July 1, 1996, should
  count as creditable coverage, reducing any
  preexisting condition exclusions after HIPAAs
  effective date.

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Special Enrollment

• Group health plans and health insurance issuers
  are required to permit certain employees and
  dependents special enrollment rights. These
  special enrollment rights permit these
  individuals to enroll without having to wait
  until the plans next regular enrollment period.
• A special enrollee is not treated as a late
  enrollee.

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Individual Provisions

• Create sub-agenda that states we will discuss
• the following topics in this section.

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Guaranteed Issue Requirement

• Insurers offering coverage in the individual
  market
• must issue to any HIPAA eligible individual a
  policy
• meeting certain requirements. They must
• Provide information about all available coverage
  options
• Enroll the individual in any coverage option the
  individual selects
• May not impose any preexisting condition
  exclusion on the individual

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Guaranteed Renewal

• All coverage sold to any individual and not just
  eligible individuals, must be renewed on a
  guaranteed basis.
• Plans may not refuse to renew a policy if the
  holder is eligible for Medicare coverage.
• If permitted by state law, policies that are sold
  to individuals before they attain Medicare
  eligibility may contain coordination of benefit
  clauses that exclude payment under the policy to
  the extent that Medicare pays.

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Alternative State Mechanisms

• The guarantee issue requirements do not apply
• in states that implements an acceptable
• alternative mechanism.

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• An acceptable alternative mechanism must
• meet all of the following requirements
• It must provide all HIPAA eligible individuals
  choice of coverage including at least one policy
  comparable to comprehensive coverage available in
  the individual market
• A standard option available under the group or
  individual insurance laws of the state
• The coverage available under the mechanism must
  not apply to any preexisting condition exclusions

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Alternative State Mechanisms

• A state that adopts one of the following National
  Association of Insurance Commissioners (NAIC)
  model acts
• The Small Employer and Individual Health
  Insurance Availability Act as adopted on June 3,
  1996
• The Individual Health Insurance Portability Act

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Alternative State Mechanisms

• A state can establish a high risk pool that meets
  
• the following requirements
• Must make coverage available to all HIPAA
  eligible individuals
• Must not apply preexisting condition exclusions
  to HIPAA eligible individuals
• Plan for Uninsurable Individuals Act

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Alternative State Mechanisms

• The risk pools premium rates must be consistent
  with in the NAIC Model Health Plan for
  Uninsurable Individuals Act, effective August 21,
  1996
• The risk pools coverage must be consistent with
  standards included in the NAIC Model Health Plan
  for Uninsurable Individuals Act

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Alternative State Mechanisms

• Any other mechanism that provides for risk
  adjustment, risk spreading, or otherwise provides
  for some financial subsidization for eligible
  individuals, including through assistance to
  participating issuers
• A mechanism that provides a choice for each
  eligible individual of all individual health
  insurance coverage otherwise available

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Certification of Coverage

• An insurer is required to issue certificates of
  coverage to individuals formerly covered under
  individual health insurance policies that it
  issued
• Both the individual policy holder and any
  dependent covered under the policy is entitled to
  receive a certificate of coverage
• Certificates must be issued upon request whenever
  a person formerly covered under an individual
  health insurance policy requests one within 24
  months of termination of coverage

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