HIPAA (the Health Insurance Portability and Accountability Act of 1996) and Recent Changes
On August 21, 1996 a new law was signed called the Health Insurance Portability and Accounting Act of 1996, which is abbreviated as HIPPA (HEP-C, 2003 & Regence, 2003). The law guarantees many things to American workers, including continuous healthcare coverage for people who are changing jobs (DC, 2003). HIPPA also includes a provision that details the manner in which health information can be disbursed, and also seeks to "combat waste, fraud, and abuse in health insurance and health care (DC, 2003). Recently rules and regulations were developed by the government that mandate new requirements for creation, storing, transmittal and care of health related data manually and electronically (DC, 2003). Additionally, a Privacy Rule was enacted that regulates the manner in which private medical and health information can be shared or disseminated among health care entities and health plan providers, which includes employers (Regence, 2003).
The HIPPA law describes certain protections that are guaranteed to citizens of the United States who have pre-existing medical conditions (HEP-C, 2003). The act also protects individuals who might be "discriminated against" when seeking out health care coverage because of "previous health conditions or other factors that are directly related to a person's health or health history" (HEP-C, 2003).
There are certain provisions that already exist in federal law, one of which is ERISA, or the Employee Retirement Income Security Act of 1974 that require "employer-sponsored group health plans" such as the health insurance one can obtain at work, "individual insurance companies and Health Maintenance Organizations, or HMO's to follow certain rules when guaranteeing coverage" (HEP-C, 2003 & Regents, 2003).
The Health Insurance Portability and Accountability Act basically add to many of the laws that are applicable to heath insurance. Particularly, HIPPA requires in part that health insurance companies, HMO's and employer sponsored insurance programs must not exclude candidates or employees seeking health insurance solely based on the fact that they have pre-existing health conditions (HEP-C, 2003). This means that if an employee who in the past had a serious health condition such as cancer applies for insurance, they can't necessarily be denied insurance coverage based solely on this fact alone. There may be certain limitations that a health insurance provider or employer can enact based on this information, depending on if they have an exclusion clause. Most clauses however, are limiting. Such situations will be described in greater detail below.
HIPPA is a protection mechanism; it protects employees and other workers from being discriminated against based on their prior health status, though it does not prohibit insurance companies from gathering information necessarily about this health statues. HIPPA also guarantees American workers that they will be allowed to renew their health insurance coverage with other employers if certain procedures are followed (HEP-C, 2003).
One additional benefit of HIPPA is that it protects workers from losing their health coverage by switching jobs or positions or similar circumstances (HEP-C, 2003). There are provisions however, in the new HIPAA law that allows employers who provide health plans and health insurers to include certain limitations or exclusions on conditions if certain requirements are met. These ideas are discussed further below.
HIPPA requires that "exclusions or limitations for eligibility based on pre-existing conditions" are limited (HEP-C, 2003). This means in most circumstances, an individual can seek health coverage even though they have a serious health illness prior to applying for health insurance. There are some limitations on this clause however. A health insurer or group health plan may exclude individuals from coverage under the following conditions:
If an individual has a pre-existing condition, the exclusion must be related to the specific condition in which "medical advice, diagnosis, care or treatment was recommended or received during the 6-month period prior to an individual's enrollment date" (HEP-C, 2003). This means that if a person sought treatment for a pre-existing condition within six months of applying for health insurance, then they may in fact be excluded from coverage for care related to this treatment. If however they have not received any care than they will not be excluded against.
The health insurance carrier or group health insurance may exclude a candidate based on a pre-existing condition, under the above circumstance, however this exclusion "may not last for more than 12 months after an individual's enrollment date" (HEP-C, 2003). This means that if an individual is suffering from a pre-existing condition, the insurance provider is still obligated to cover the individual after a period of 12 months.
The provision for a 12-month waiting period "must be reduced by the number of days of an individuals prior creditable coverage" HEP-C, 2003), meaning that it is feasible that an employee could wait less than 12 months before they are allowed to be covered under the new plan.
Some may be wondering how HIPPA is helpful if health insurance plans can still make exclusions for health care coverage based on pre-existing conditions. I truth however, HIPPA helps by limiting the time in which these conditions can exist, so that individual employees can after a period of time (Typically no more than 12 months) still acquire adequate health care coverage (HEP-C, 2003).
How does this affect an employee who is moving from one company to another? If an employee switches jobs, but had 6 months of health care coverage at their previous place of employment, the 12-month exclusion period must be reduced to 6 months because the employee is credited for time they were covered under the old health plan (HEP-C, 2003). It is important to note in this situation that if a break in health coverage existed, it must not exceed 63 days in length, or the employee will be required to wait out the entire 12-month period (HEP-C, 2003).
There are certain conditions that pre-existing conditions cannot be excluded from. These include "pregnancy, newborn care, care for child who is adopted under age 18" (HEP-C, 2003). Typically such situations are required to be covered even if the individual in question had no prior coverage when applying for health care insurance. Such measures are deemed important to the protection of children.
ADMINISTRATIVE SIMPLIFICATION OF HIPPA
The new HIPPA mandate also includes standards and regulations for improving the efficiency of data management related to healthcare. The aim of these regulations is to prevent fraud and abuse that may occur in health plans, and "simplify administrative aspects of health care" (DC, 2003).
HIPPA currently mandates "the use of national standards for electronic exchange of health care data" (DC, 2003) meaning that all health care facilities, employers and health insurance carriers are required to process electronic claims and patient data following the same set of standards, in an effort to reduce paper flow and make the process of processing claims more efficient and user friendly (DC, 2003).
As recently as February 20, 2003 a final privacy rule was passed adopting HIPPA standards that secure the manner in which electronic health information can be published (HRSA, 2003). The new regulation specifies particular "technical, physical and administrative procedures" that must be followed in order to guarantee that health information for employees and patients is kept confidential in nature (HRSA, 2003).
The new mandate regarding HIPPA that has been enacted may be referred to as the Privacy Rule. The Privacy Rule in layman's terms requires employers and health providers or plans to guarantee confidentiality of health care information. Specifically, the Privacy Rule requires the following of health plan providers:
Patients must be notified about their right to privacy" under the new HIPPA law, and must be notified regarding how any of their medical information or patient history may be used by a health care provider or insurer (HHS, 2003).
Employees must be trained to understand new privacy procedures" (HHS, 2003).
An individual must be designated within an organization that is responsible for ensuring that privacy procedures are followed" (HHS, 2003). This person is usually a HR Manager or Benefits Manager
An organization or health insurance provider must secure all patient records and files that contain any "identifiable health information" in a secure place separate from individual employee files, and these files should not be made available to individuals who do not require knowledge of medical information (HHS, 2003)
The privacy rule covers any and all health insurance plans, health care clearinghouses and health care providers such as hospitals and physicians offices that may be involved in processing financial and administrative transactions (HHS, 2003). The new privacy rule requires that individuals, corporations and health representatives take reasonable precautionary measures to ensure the confidentiality of patient health information. In the case of an employee/employer relationship, this means that the employer must take an active role when communicating with patients to ensure that only minimal information is disclosed regarding medical information when deemed medically necessary. The Privacy rule does allow disclosure of limited information to family member or persons caring for an individual, however such disclosures must…
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