Chapter 1

1. HIPAA for Allied Health Careers Chapter 1 The Goal of HIPAA: Administrative Simplification

2. LEARNING OUTCOMES After studying this chapter, you should be able to: 1. Discuss the reasons for passage of the Health Insurance Portability and Accountability Act (HIPAA). 2. Differentiate between the two major provisions of HIPAA, Title I and Title II. 3. Discuss the improvements to health insurance coverage under Title I. 4. Identify the five key provisions of HIPAA Administrative Simplification. 5. Define the concept of preemption. 6. List the four areas in which standards under HIPAA Administrative Simplification have been legislated. 7. Describe the HIPAA rule-making process. 8. Describe the types of facilities and health care professionals who are considered covered entities under HIPAA. 9. Differentiate between a covered entity and a business associate. 10. Describe how allied health personnel can keep up with HIPAA standards and enforcement in their careers.

3. Administrative Simplification business associate (BA) Centers for Medicare and Medicaid Services (CMS) clearinghouse Consolidated Omnibus Budget Reconciliation Act (COBRA) covered entity (CE) creditable coverage Department of Health and Human Services (HHS) direct provider electronic data interchange (EDI) Federal Employees Health Benefits (FEHB) program Federal Register group health plan (GHP) Key Terms

4. Health Insurance Portability and Accountability Act (HIPAA) of 1996 health insurance reform health plan indirect provider Notice of Proposed Rule-Making (NPRM) Office for Civil Rights (OCR) preemption provider small health plan Title I (health insurance reform) Title II (Administrative Simplification) transaction KEY TERMS (cont’d)

5. HIPAA is the Health Insurance and Portability Act of 1996. HIPAA has two parts: Title I and Title II The three main purposes of HIPAA are: 1. Increase health care efficiency and effectiveness. 2. Protect and enhance patient rights. 3. Restore trust in the health care system. What Is HIPAA?

6. Insurance Background Private insurance includes Employer-sponsored group health plans Federal Employees Health Benefits Program (FEHB) Individual Plans Federal programs, such as Medicare and Medicaid are also covered by other federal laws. Title I: Health Insurance Reform

7. Portability and Required Coverage: COBRA and HIPAA. Title I: Limits exclusions for preexisting conditions and prohibit discrimination based on health status. Employees with creditable coverage get special enrollment opportunities. After exhausting COBRA, some individuals may purchase individual plans. Title I: Health Insurance Reform (cont’d)

8. Additional Laws Affecting the Availability of Insurance Coverage Newborns’ and Mothers’ Health Protection Act—covers length of hospital stays after childbirth. Women’s Health and Cancer Rights Act—covers hospital stays and breast reconstruction after cancer. Mental Health Parity Act—provides parity for mental health benefits (except for substance abuse or chemical dependency). Title I: Health Insurance Reform (cont’d)

9. Purpose and Extent of Administrative Simplification Cut costs by using electronic data interchange (EDI) Each exchange is a transaction. Title II: Administrative Simplification

10. Administrative Simplification Standards HHS had to establish standards. Five provisions are: Standards for electronic health transactions. Mandated use of standards. Privacy regulations. Preemption of state law. Penalties for violation. Title II: Administrative Simplification (cont’d)

11. HIPAA standards have three main areas: Privacy standards Security standards Electronic transactions The Office of Civil Rights (OCR) is responsible for HIPAA enforcement. Centers for Medicare and Medicaid (CMS) is the federal agency responsible for health care. Title II: Administrative Simplification (cont’d)

12. Rule-Making Process Rule is drafted and reviewed. A Notice of Proposed Rule-Making (NPRM) is released. Public comment time is set. Rule is revised by HHS. Final rule is published in the Federal Register. Title II: Administrative Simplification (cont’d)

13. A covered entity is: An organization or professional who provides health care An organization or professional who transmits health information electronically Covered Entities: Complying with HIPAA

14. Covered Entities: Health Plans, Providers, and Clearinghouses Three types of covered entities must adhere to HIPAA 1. Health plans 2. Providers 3. Clearinghouses Covered Entities: Complying with HIPAA (cont’d)

15. Health plans include: Group health plans Health insurance issuers Most parts of Medicare Medicaid Issuers of Medicare supplemental policies Issuers of most long-term care policies Employee benefit plans that include health care Tricare Champva Covered Entities: Complying with HIPAA (cont’d)

16. Health plans (cont’d) The Indian Health Service The Federal employees Health Benefits Program (FEHB) Approved state child health plans State high-risk pools Other plans paying for medical care under the Public Health Service Act Covered Entities: Complying with HIPAA (cont’d)

17. Providers Hospitals Critical access hospitals Skilled nursing facilities Comprehensive outpatient rehabilitation facilities Hospices Home health agencies Pharmacies Covered Entities: Complying with HIPAA (cont’d)

18. Providers (cont’d) Physician practices Dental practices Chiropractors Podiatrists Osteopaths Therapists Laboratories Covered Entities: Complying with HIPAA (cont’d)

19. Clearinghouses Companies that help providers with electronic transactions and recordkeeping Convert health information to meet HIPAA standards Covered Entities: Complying with HIPAA (cont’d)

20. Business Associates Law firms Accreditation agencies Accountants IT contractors Medical transcription companies Independent contractors working for CEs Collection agencies Third-party claim administrators (TPAs) Covered Entities: Complying with HIPAA (cont’d)

21. HIPAA outreach Listserv HHS home page The National Committee on Vital and Health Statistics (NCVHS) The Accredited Standards Committee (ASC X12) The National Council for Prescription Drug Programs (NCPDP) Staying Up to Date

22. Designated Standard Maintenance Organizations (DSMO) X12 implementation guides Workgroup for Electronic Data Interchange (WEDI) Strategic National Implementation Process (SNIP) Medicare Electronic Data Interchange (EDI) Staying Up to Date (cont’d)