Things you need to understand about HIPAA?

  • Things you need to understand about HIPAA?

    Posted by Peter Lewis on October 25, 2022 at 2:00 pm

    What is Hipaa and what is its purpose?

    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge.

    Things you need to understand about HIPAA?

    The Health Insurance Portability and Accountability Act of 1996 (HIPAA or the Kennedy–Kassebaum Act) is a United States federal statute enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1996. It was created primarily to modernize the flow of healthcare information, stipulate how personally identifiable information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and address limitations on healthcare insurance coverage.

    The act consists of five titles. Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. Title III sets guidelines for pre-tax medical spending accounts, Title IV sets guidelines for group health plans, and Title V governs company-owned life insurance policies.

    There are five sections to the act, known as titles:

    Title I: Health Care Access, Portability, and Renewability-

    Title I of HIPAA regulates the availability and breadth of group health plans and certain individual health insurance policies. It amended the Employee Retirement Income Security Act, the Public Health Service Act, and the Internal Revenue Code. Title I requires the coverage of and also limits restrictions that a group health plan can place on benefits for preexisting conditions. Group health plans may refuse to provide benefits in relation to preexisting conditions for either 12 months following enrollment in the plan or 18 months in the case of late enrollment. Title I allows individuals to reduce the exclusion period by the amount of time that they have had “creditable coverage” before enrolling in the plan and after any “significant breaks” in coverage. “Creditable coverage” is defined quite broadly and includes nearly all group and individual health plans, Medicare, and Medicaid. A “significant break” in coverage is defined as any 63-day period without any creditable coverage. Along with an exception, allowing employers to tie premiums or co-payments to tobacco use, or body mass index.

    Title I also requires insurers to issue policies without exclusion to those leaving group health plans with creditable coverage exceeding 18 months, and renew individual policies for as long as they are offered or provide alternatives to discontinued plans for as long as the insurer stays in the market without exclusion regardless of health condition. Some health care plans are exempt from Title I requirements, such as long-term health plans and limited-scope plans like dental or vision plans offered separately from the general health plan. However, if such benefits are part of the general health plan, then HIPAA still applies to such benefits. For example, if the new plan offers dental benefits, then it must count creditable continuous coverage under the old health plan towards any of its exclusion periods for dental benefits. An alternate method of calculating creditable continuous coverage is available to the health plan under Title I. That is, 5 categories of health coverage can be considered separately, including dental and vision coverage. Anything not under those 5 categories must use the general calculation.

    Since limited-coverage plans are exempt from HIPAA requirements, the odd case exists in which the applicant to a general group health plan cannot obtain certificates of creditable continuous coverage for independent limited-scope plans, such as dental to apply towards exclusion periods of the new plan that does include those coverages. Hidden exclusion periods are not valid under Title I. Such clauses must not be acted upon by the health plan. Also, they must be re-written so they can comply with HIPAA.

    Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform-

    Title II of HIPAA establishes policies and procedures for maintaining the privacy and the security of individually identifiable health information, outlines numerous offenses relating to health care, and establishes civil and criminal penalties for violations. It also creates several programs to control fraud and abuse within the health-care system. However, the most significant provisions of Title II are its Administrative Simplification rules. Title II requires the Department of Health and Human Services (HHS) to increase the efficiency of the health-care system by creating standards for the use and dissemination of health-care information. These rules apply to “covered entities”, as defined by HIPAA and the HHS. Covered entities include health plans, health care clearinghouses (such as billing services and community health information systems), and health care providers that transmit health care data in a way regulated by HIPAA. Per the requirements of Title II, the HHS has promulgated five rules regarding Administrative Simplification: the Privacy Rule, the Transactions and Code Sets Rule, the Security Rule, the Unique Identifiers Rule, and the Enforcement Rule.

    1. Privacy Rule-

      The HIPAA Privacy Rule is composed of national regulations for the use and disclosure of Protected Health Information (PHI) in healthcare treatment, payment and operations by covered entities. The effective compliance date of the Privacy Rule was April 14, 2003, with a one-year extension for certain “small plans”. The HIPAA Privacy Rule regulates the use and disclosure of protected health information (PHI) held by “covered entities” (generally, health care clearinghouses, employer-sponsored health plans, health insurers, and medical service providers that engage in certain transactions). By regulation, the HHS extended the HIPAA privacy rule to independent contractors of covered entities who fit within the definition of “business associates”. PHI is any information that is held by a covered entity regarding health status, provision of health care, or health care payment that can be linked to any individual. This is interpreted rather broadly and includes any part of an individual’s medical record or payment history. Covered entities must disclose PHI to the individual within 30 days upon request. Also, they must disclose PHI when required to do so by law such as reporting suspected child abuse to state child welfare agencies.

    2. 2013 Final Omnibus Rule Update-
      In January 2013, HIPAA was updated via the Final Omnibus Rule. The updates included changes to the Security Rule and Breach Notification portions of the HITECH Act. The most significant changes related to the expansion of requirements to include business associates, where only covered entities had originally been held to uphold these sections of the law. In addition, the definition of “significant harm” to an individual in the analysis of a breach was updated to provide more scrutiny to covered entities with the intent of disclosing breaches that previously were unreported. Previously, an organization needed proof that harm had occurred whereas now organizations must prove that harm had not occurred. Protection of PHI was changed from indefinite to 50 years after death. More severe penalties for violation of PHI privacy requirements were also approved. The HIPAA Privacy rule may be waived during natural disasters. This was the case with Hurricane Harvey in 2017.
    3. Right to access your PHI-
      The Privacy Rule requires medical providers to give individuals access to their PHI. After an individual requests information in writing (typically using the provider’s form for this purpose), a provider has up to 30 days to provide a copy of the information to the individual. An individual may request the information in electronic form or hard-copy, and the provider is obligated to attempt to conform to the requested format. For providers using an electronic health record (EHR) system that is certified using CEHRT (Certified Electronic Health Record Technology) criteria, individuals must be allowed to obtain the PHI in electronic form. Providers are encouraged to provide the information expediently, especially in the case of electronic record requests.
    4. Disclosure to relatives-
      According to their interpretations of HIPAA, hospitals will not reveal information over the phone to relatives of admitted patients. This has in some instances impeded the location of missing persons. After the Asiana Airlines Flight 214 San Francisco crash, some hospitals were reluctant to disclose the identities of passengers that they were treating, making it difficult for Asiana and the relatives to locate them. In one instance, a man in Washington state was unable to obtain information about his injured mother. Janlori Goldman, director of the advocacy group Health Privacy Project, said that some hospitals are being “overcautious” and misapplying the law, the Times reports. Suburban Hospital in Bethesda, Md., has interpreted a federal regulation that requires hospitals to allow patients to opt out of being included in the hospital directory as meaning that patients want to be kept out of the directory unless they specifically say otherwise. As a result, if a patient is unconscious or otherwise unable to choose to be included in the directory, relatives and friends might not be able to find them, Goldman said.
    5. Transactions and Code Sets Rule-
      HIPAA was intended to make the health care system in the United States more efficient by standardizing health care transactions. HIPAA added a new Part C titled “Administrative Simplification” to Title XI of the Social Security Act. This is supposed to simplify healthcare transactions by requiring all health plans to engage in health care transactions in a standardized way. The HIPAA/EDI (electronic data interchange) provision was scheduled to take effect from October 16, 2003, with a one-year extension for certain “small plans”. However, due to widespread confusion and difficulty in implementing the rule, CMS granted a one-year extension to all parties. On January 1, 2012 newer versions, ASC X12 005010 and NCPDP D.0 became effective, replacing the previous ASC X12 004010 and NCPDP 5.1 mandate. The ASC X12 005010 version provides a mechanism allowing the use of ICD-10-CM as well as other improvements. Key EDI (X12) transactions used for HIPAA compliance are: EDI Health Care Claim Transaction set (837), EDI Retail Pharmacy Claim Transaction (NCPDP Telecommunications Standard version 5.1), EDI Health Care Claim Payment/Advice Transaction Set (835), EDI Benefit Enrollment and Maintenance Set (834), EDI Payroll Deducted and another group Premium Payment for Insurance Products (820), EDI Health Care Eligibility/Benefit Inquiry (270), EDI Health Care Eligibility/Benefit Response (271), EDI Health Care Claim Status Request (276), EDI Health Care Claim Status Notification (277), EDI Health Care Service Review Information (278) and EDI Functional Acknowledgement Transaction Set (997).
    6. Brief 5010 Transactions and Code Sets Rules Update Summary-

      Transaction Set (997) will be replaced by Transaction Set (999) “acknowledgment report”.
      The size of many fields {segment elements} will be expanded, causing a need for all IT providers to expand corresponding fields, elements, files, GUI, paper media, and databases.
      Some segments have been removed from existing Transaction Sets.
      Many segments have been added to existing Transaction Sets allowing greater tracking and reporting of cost and patient encounters.

      Capacity to use both “International Classification of Diseases” versions 9 (ICD-9) and 10 (ICD-10-CM) has been added. Security Rule- The Final Rule on Security Standards was issued on February 20, 2003. It took effect on April 21, 2003, with a compliance date of April 21, 2005, for most covered entities and April 21, 2006, for “small plans”.[citation needed]The Security Rule complements the Privacy Rule. While the Privacy Rule pertains to all Protected Health Information (PHI) including paper and electronic, the Security Rule deals specifically with Electronic Protected Health Information (EPHI). It lays out three types of security safeguards required for compliance: administrative, physical, and technical. For each of these types, the Rule identifies various security standards, and for each standard, it names both required and addressable implementation specifications. Required specifications must be adopted and administered as dictated by the Rule. Addressable specifications are more flexible. Individual covered entities can evaluate their own situation and determine the best way to implement addressable specifications. Some privacy advocates have argued that this “flexibility” may provide too much latitude to covered entities.

    Title III: Tax-related health provisions governing medical savings accounts-

    Title III standardizes the amount that may be saved per person in a pre-tax medical savings account. Beginning in 1997, medical savings account (“MSA”) are available to employees covered under an employer-sponsored high deductible plan of a small employer and self-employed individuals.

    Title IV: Application and enforcement of group health insurance requirements-

    Title IV specifies conditions for group health plans regarding coverage of persons with pre-existing conditions, and modifies continuation of coverage requirements. It also clarifies continuation coverage requirements and includes COBRA clarification.

    Title V: Revenue offset governing tax deductions for employers-

    Title V includes provisions related to company-owned life insurance for employers providing company-owned life insurance premiums, prohibiting the tax-deduction of interest on life insurance loans, company endowments, or contracts related to the company. It also repeals the financial institution rule to interest allocation rules. Finally, it amends provisions of law relating to people who give up United States citizenship or permanent residence, expanding the expatriation tax to be assessed against those deemed to be giving up their U.S. status for tax reasons, and making ex-citizens’ names part of the public record through the creation of the Quarterly Publication of Individuals Who Have Chosen to Expatriate.

    Aradhna Singhania replied 11 months, 1 week ago 2 Members · 1 Reply
  • 1 Reply
  • Aradhna Singhania

    August 7, 2023 at 8:18 am

    HIPAA, the Health Insurance Portability and Accountability Act of 1996, holds a vital role in safeguarding sensitive patient health information. By establishing national standards, it ensures the protection of patient data, preventing unauthorized disclosures. For comprehensive HIPAA audit and certification services, ensuring compliance and data security, explore: Accorp Partners HIPAA Audit & Certification Services Your patients’ confidentiality is our priority.


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