Health Insurance Portability Accountability Act (HIPAA)

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These executive summaries were compiled from EMPLOYEE BENEFITS INFOSOURCE database, a source for information on employee benefits and human resources.

The Dual Problems of Chronic Pain and Prescription Misuse.
Strickland, Jennifer; Employee Benefit Plan Review; v67 no3 pp 11-14 Mar 2012; journal article

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Abstract : Chronic pain is a debilitating and complex secondary condition resulting from a number of primary conditions or from unresolved acute pain. According to Laffer Associates and the Millennium Research Institute, it accounts for $323 billion in direct and indirect costs annually, and the American Pain Society reports it leads to the loss of over 50 million work days each year. But physicians are often reluctant to prescribe opioid analgesics because of regulatory obstacles, and some patients choose to avoid these drugs, despite their effectiveness. Physicians can navigate the challenges by following a standard pain management protocol with objective measurement through urine drug testing. HR staff should be involved, recognizing signs of chronic pain and communicating with employees, always complying with the Health Insurance Portability and Accountability Act and the Americans with Disabilities Act.
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Wellness Rewards.
Wells, Susan J.; HR Magazine; v57 no2 pp 67-69 Feb 2012; journal article

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Abstract : Health insurance premium discounts have overtaken gifts and cash as the reward for healthy behavior. This incentive, with a clear and direct link to employee accountability on health, has become the most common reward according to a Mercer survey, with the median annual discount being $240. Iowa's Spencer Hospital shifted its wellness strategy to require wellness screenings and blood work, as well as special program participation for smokers and those with metabolic risk factors. Domino's Pizza LLC and other firms have moved beyond simply encouraging participation to results-oriented strategies. But federal laws ban programs that discriminate by penalizing those who cannot participate fully or achieve certain results. Employers must make reasonable accommodations and should offer alternatives, such as rewarding progress toward goals.
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Health Care: Consumer Group Outlines Problems With Employer Wellness Program Designs.
Hansard, Sara; Daily Labor Report; no15 p A5 Jan 24, 2012; journal article

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Abstract : Analysts explained to attendees at a Families USA conference that wellness programs can be a barrier in disguise, interfering with good health care. Programs with incentives based on achieving certain results function as medical underwriting, hurting access to coverage and care and increasing costs based on participation. Those with greater health risks and/or low income feel the impact the most, since they may be unable to achieve health outcome goals or even to participate because of other demands on time and resources. Employers' authority under the Health Insurance Portability and Accountability Act to vary premium cost sharing up to 20 percent and higher will add to the hardship, with the surcharge making health insurance unaffordable for some.
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Fit for an On-Site Clinic.
Oliphant, Lori Thayer; Murray, Cheryl Camin; HR Magazine; v57 no1 pp 61, 63, 65 Jan 2012; journal article

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Abstract : While on-site health clinics were originally geared toward occupational illness, most are now similar to a primary care physician's office or urgent care center. The goal remains to save on medical costs through greater control and often broader inclusion of employees' spouses, beneficiaries and retirees. Employers considering sponsoring an on-site clinic face many decision points including the covered group, the scope of service, payment sharing, staffing, the physical facility and maintenance, ongoing management and return on investment. Clinics usually need 1,000 or more employees to be worthwhile. Since they face a maze of federal and state laws, a feasibility study should be carried out by a team of professionals including representatives from finance, benefits and legal departments along with outside consultants.
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Wellness Programs: A Complex Cure.
Linder, Debra J.; Hatcher, Krista A.P.; Employee Benefit Plan Review; v66 no6 pp 5-6 Dec 2011; journal article

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Abstract : There are strong reasons for employers to offer wellness programs, as about two out of three do in 2011, according to the Kaiser Family Foundation. But employers must be aware of the maze of regulations, both federal and state, that affect aspects of their programs. The Health Insurance Portability and Accountability Act prohibits program incentives based on health factors and strictly limits conditions for participation rewards. The Americans with Disabilities Act bars discrimination on the basis of disability and requires reasonable accommodation for the disabled, requires the program be voluntary and mandates confidentiality of records. The Genetic Information Nondiscrimination Act prohibits use of any genetic information for health plan and wellness program decisions. Employers should also attend to provisions of the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, ERISA and the Internal Revenue Code as well as state laws that interact with wellness program design.
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Educating Former Employees on Post-COBRA Subsidy Health Insurance Options.
Matalluci, Gary; Daily Labor Report; no227 p I1 Nov 25, 2011; journal article

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Abstract : The federal subsidy for COBRA ended in August 2011, leaving many former employees looking for alternatives for health insurance which will be at substantially higher costs. HR can help former employees move to another insurance arrangement, providing education about options and directing them to additional resources. Alternatives to consider include preexisting condition insurance plans under the Patient Protection and Affordable Care Act, individually purchased plans and guaranteed issue plans for dependents under age 18. Coverage through a working spouse's plan, short-term health insurance and government sponsored options may also be available. HR should be sure former employees know their rights through the Health Insurance Portability and Accountability Act when they maintain creditable coverage without a significant gap.
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Preemption: Appeals Court Finds State Law Preempted From Halting Use of Health Status Premiums.
BNA's Pension & Benefits Reporter; v38 p 1963 Oct 25, 2011; journal article

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Abstract : In Fossen v. Blue Cross and Blue Shield of Montana Inc., the Ninth Circuit Court of Appeals ruled that ERISA preempts a Montana law prohibiting insurers to charge more in premiums based on the health status of the insured. The court upheld a district court ruling that the law, called little HIPAA, mirrored a section of the Health Insurance Portability and Accountability Act (HIPAA), which is incorporated into ERISA. The appeals court reversed the lower court's grant of summary judgment on an unfair insurance practices claim and remanded it for review.
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Educating Former Employees on Post-COBRA Subsidy Health Insurance Options.
Matalluci, Gary; BNA's Pension & Benefits Reporter; v38 p 1842 Oct 4, 2011; journal article

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Abstract : August 2011 was the end of federal COBRA subsidies, leaving many former employees unsure where to get health coverage. Human resource personnel have a final opportunity to educate their former employees as they seek health insurance. COBRA may be a less attractive option for many than preexisting condition insurance plans, individual health plans or guaranteed issue plans for minor dependents. Other alternatives to consider are joining a spouse's plan, short-term health insurance, guaranteed issue plans under the Health Insurance Portability & Accountability Act of 1996 and state sponsored high-risk insurance pools.
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Health Care Reform: HHS Releases Interim Final Rule Outlining Operating Rules for Two HIPAA Transactions.
Douglas, Genevieve; BNA's Pension & Benefits Reporter; v38 p 1252 Jul 5, 2011; journal article

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Abstract : An interim final rule from the Department of Health and Human Services (HHS) is expected to lower transaction costs for health plans, care providers and health care clearinghouses by about $12 billion over ten years. The rule, effective January 1, 2013, affects electronic health care transactions relating to patient coverage eligibility and claim status. Transactions will have to follow standard operating rules, substantially simplifying administration. The HHS rule adopts most of what was proposed by the Council for Affordable and Quality Healthcare's Committee on Operating Rules for Information Exchange and implements Section 1104 of the Patient Protection and Affordable Care Act. Further rules are expected on electronic funds transfer, standard health plan identifying codes and claims attachments.
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"Well" Wishes.
PLANSPONSOR; v19 no4 pp 44-45 Jul 2011; journal article

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Abstract : The Patient Protection and Affordable Care Act (PPACA) adopted several aspects of wellness programs that were established under the Health Insurance Portability and Accountability Act (HIPAA). One change increases the cost amount for health-based rewards from 20 percent of coverage cost to 30 percent starting in 2014, with the possibility of the Department of Health and Human Services raising the cap to 50 percent. The incentive limit applies only to programs that rewards participants for achieving a health standard such as not smoking or being under a certain cholesterol level. Mere program participation does not count toward the 20 percent limit. Incentives may be rewards or penalties, and there must be an alternative method of achieving incentives for those who are medically unable to take the usual approach. Wellness program must consider the PPACA, HIPAA, the Americans with Disabilities Act, ERISA and IRS rules.
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Employee Medical Information: When, What, Where and How You May Get It, Store It and Share It Under the ADA and FMLA.
Panaro, Gerard P.; HR Advisor: Legal & Practical Guidance; v17 no4 pp 43-51 Jul-Aug 2011; journal article

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Abstract : Numerous federal and state laws pertaining to medical leave interact in complex, overlapping, sometimes inconsistent and often confusing ways. Best practices for handling employee medical information start with limiting the information requested to the minimum necessary and sharing it with only those who absolutely need to know. Anyone with hiring and firing authority should be isolated from medical information. Under the Americans with Disabilities Act (ADA), information requested must relate directly to a job and be necessary for business operations. The ADA also requires that wellness and health screening programs be voluntary, with information kept confidential and never used to discriminate against the employee. The Family and Medical Leave Act (FMLA) has simpler requirements, and the DOL provides boilerplate forms for certification supporting leave requests. The intersection of FMLA leave with workers compensation and ADA disability involves additional considerations. Privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA) must be satisfied throughout, and state and local law as well as collective bargaining agreement provisions also come into play.
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Keeping Pace: The Role of Technology in Regulatory Compliance.
Wekluk, Bill; Benefits Magazine; v48 no6 pp 26-32 Jun 2011; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : The Health Insurance Portability and Accountability Act, Health Information Technology for Economic and Clinical Health (HITECH), health care reforms and other laws include technology as an integral part of their initiatives, emphasizing technology's role to aid regulatory compliance. These laws include requirements for technology-based activities such as electronic data transfer using specific formats, electronic health records, plan member notifications and data mining. Plan sponsors should coordinate with technology vendors to ensure their computer systems are up to the tasks required. Compliance rules are not static, evolving over months, requiring plan sponsors to stay current with changes.
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Link To Full Article
HIPAA Privacy Rule Accounting of Disclosures Under the Health Information Technology for Economic and Clinical Health Act: Notice of Proposed Rulemaking.
Federal Register; v76 no104 pp 31426-31449 May 31, 2011; journal article

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Abstract : The Department of Health and Human Services (HHS) proposes a rule modifying the standard for accounting of disclosures of protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act of 1996. The modification is in part to satisfy a provision of the Health Information Technology for Economic and Clinical Health Act requiring accounting for disclosures made through an electronic health record. The proposed rule would give individuals the right to receive a report showing who has accessed electronic PHI. It would also change accounting requirements for improved ease of use and effectiveness. The HHS is taking comments on the proposed rule through August 1, 2011.
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HIPAA's Potential Impact on FMLA Certification.
Lampe, David J.; Employee Benefit Plan Review; v65 no10 pp 12-13 Apr 2011; journal article

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Abstract : While the Family and Medical Leave Act (FMLA) allows employers to require medical information to determine if requested leave qualifies, the Health Insurance Portability and Accountability Act (HIPAA) generally prohibits a health care provider from divulging protected health information that may be required for FMLA purposes. When an employee is given FMLA certification forms, the employer should include a HIPAA authorization allowing the employee's provider to release protected information to the employer. Employers may contact providers to clarify a FMLA certification request, but HIPAA rules still apply and the employer's representative in such communications may not be the employee's supervisor. Employers may request FMLA recertification, so the HIPAA authorization should have an expiration date that allows reuse.
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Privacy: HHS Issues First-Ever Civil Monetary Penalty for Privacy Rules Violations, Fines Company.
Pazanowski, Mary Anne; BNA's Pension & Benefits Reporter; v38 p 420 Mar 1, 2011; journal article

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Abstract : Cignet Health was penalized $3 million for violating the privacy rule in the Health Insurance Portability and Accountability Act (HIPAA), a first by the Department of Health and Human Services' Office for Civil Rights (OCR). Cignet failed to respond to requests from multiple patients for medical records and to the OCR's subpoena, impeding the investigation. The Health Information Technology for Economic and Clinical Health Act (HITECH) conveys expanded enforcement authority to the OCR, which targeted Cignet's failure to cooperate with the investigation. It is not clear whether this is an isolated case or the start of more aggressive enforcement of HIPAA rules.
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Imprudent Advice to Terminate Group Health Insurance.
Conlin, R. Dean; Farber, Timothy S.; Hansen, Laurence A.; Employee Benefit Plan Review; v65 no9 pp 24-28 Mar 2011; journal article

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Abstract : In the wake of the Patient Protection and Affordable Care Act, some producers and consultants are advising small employers to terminate group health insurance and provide workers with money to buy their own insurance. Despite the reassurances of those advising termination, most workers given such funds will not be eligible for most state health insurance pools. They may be subject to exclusions due to preexisting conditions and may have to pay taxes on their health coverage. Also, employers will find that if they create an arrangement that allows employees to pay for health coverage tax free they will still be subject to requirements under ERISA, COBRA and other federal laws covering group health plans.
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Health Insurance Answer Book.
Garner, John C.; 1,216 pp 2011 10th ed.; book

Availability : International Foundation of Employee Benefit Plans
Abstract : Provides succinct answers to an extremely broad range of health insurance topics—plan design, funding, federal and state regulation, cost management, quality assurance, communication and more. Addresses related topics such as dental insurance, vision coverage, mental health treatment, Medicare, employee assistance programs and wellness. Contains several model COBRA notices and a sample QMCSO procedure.
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Link To Full Article
HHS Proposes Rewrite of HIPAA Privacy and Data Security Rules.
Holloway, Mark; Fensholt, Edward; Benefits Law Journal; v23 no4 pp 66-71 Winter 2010; journal article

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Abstract : The Department of Health and Human Services (HHS) has proposed a rewrite of the privacy and data security regulations enacted under the Health Insurance Portability and Accountability Act (HIPAA). Among the proposed changes are new rules regarding business associates, i.e., health plan service providers. HHS proposes requiring business associates to ensure that all of their subcontractors are held to the same standards as they are, report breaches of personal health information and be held liable for failing to perform a contracted HIPAA obligation of the plan. The HHS also proposes a number of additions to plans' required privacy notices.
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Tips to Avoid Common Employee Benefit Mistakes and Misconceptions.
Koster, Kathleen; Employee Benefit News; v24 no12 pp 14-15 Sep 15, 2010; journal article

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Abstract : Sheldon Blumling of Fisher & Phillips LLP offers advice to help benefit professionals and plan sponsors stay out of trouble, starting with keeping plan documents updated and following them in detail. It is also important to precisely define and comply with eligibility requirements and, for cafeteria plans, carefully explain in plan documents how pretax employee premiums are handled. Compliance with COBRA requires attention to multiple health and other benefits and at least two notifications. Other problem areas include compliance with the Health Insurance Portability and Accountability Act, nondiscrimination in welfare benefit plans, annual filing of IRS Form 5500 and taxability of benefits for domestic partners and their children.
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Butting In.
Huff, Charlotte; Workforce Management; v89 no8 pp 22, 24, 26 Aug 2010; journal article

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Abstract : Employers are increasingly turning to incentives and/or penalties to motivate employees to stop unhealthy behaviors and adopt more beneficial ones. Hewitt found in 2010 almost two-thirds of 600 large employers penalize smokers or will start soon. Navistar Inc. requires smokers to pay $50 more on monthly health insurance premiums. Their percentage of smokers fell from 10.3 percent in 2005 to 8.6 percent in 2009. While there is concern about intruding into employees' lives, employers have a vested interest in their health. Health programs must be carefully designed to avoid legal complications with the Health Insurance Portability and Accountability Act (HIPAA). Under HIPAA, wellness programs can tie 20 percent of insurance premiums to individual wellness goals, rising to 30 percent in 2014. The law prohibits any discrimination in incentives and encourages alternative paths to incentives. While incentives may have some effect for the short term, their lasting effect is uncertain, and employers question how they might end financial incentives.
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Health Care Reform and Limited Medical Plans.
Robertson, Brian; Broker World; v30 no8 pp 26, 28 Aug 2010; journal article

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Abstract : The impact of the Patient Protection and Affordable Care Act (PPACA) varies by what benefits a plan offers and whether it meets grandfather provisions. Group plans with participants on March 23, 2010 are grandfathered but still must meet requirements for essential health benefits. These include the absence of any lifetime or annual benefit limit, effective for plan renewals from September 24, 2010 on and for all plans starting January 1, 2014. The PPACA regulations apply starting September 23, 2010 to group limited medical plans that require coinsurance and issue letters of creditable coverage under the Health Insurance Privacy and Portability Act (HIPAA). Since plans with lifetime or annual limits will be ineligible for renewal under these PPACA rules, employers should consider coverage with a fixed indemnity plan, though rates will increase significantly.
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Modifications to the HIPAA Privacy, Security, and Enforcement Rules Under the Health Information Technology for Economic and Clinical Health Act: Notice of Proposed Rulemaking.
Federal Register; v75 no134 pp 40868-40924 Jul 14, 2010; journal article

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Abstract : The Department of Health and Human Services is proposing rules to modify standards under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for personal health information privacy, security and enforcement. The modifications would implement changes to HIPAA under the Health Information Technology for Economic and Clinical Health Act of 2009. Health and Human Services has also taken the opportunity to improve and update the HIPAA rules, many of which have not had substantial revision in several years.
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Privacy: HHS Releases Proposed HIPAA Rule Extending Mandate to Business Associates.
Plank, Kendra Casey; BNA's Pension & Benefits Reporter; v37 p 1593 Jul 13, 2010; journal article

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Abstract : Provisions of the Health Insurance Portability and Accountability Act (HIPAA) will extend to health care entities' business associates and subcontractors under a Department of Health and Human Services (HHS) rule announced July 8, 2010. The purpose is to further protect patients' information privacy and security. The Health Information Technology for Economic and Clinical Health (HITECH) Act requires the extension with the same enforcement actions to associates and subcontractors, who will have 180 days after final rule publication to comply. The broad inclusion was unexpected and presents a burden for subcontractors who may have felt far removed from security issues to be affected by HIPAA. Comments to HHS will be accepted until September 13, 2010.
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PPO Repricers: The EDI Perspective.
Doyle, Stephanie; Benefits & Compensation Digest; v47 no7 pp 24-27 Jul 2010; journal article

Availability : International Foundation of Employee Benefit Plans
Abstract : A key factor in the competition among preferred provider organization (PPO) networks is how PPO repricers, contracting with the PPO, handle electronic submissions of out-of-network claims. Processing methods requiring paper or manual intervention are outdated. Under the Health Insurance Portability and Accountability Act (HIPAA), the 837 electronic claim format became the standard, allowing efficient and secure electronic data interchange (EDI) for claims adjudication. Virtually all claim repricing approaches for EDI transactions fall one of into three types, a simple send and receive process with the fund office, receive only, or shared administration between the repricer and the fund office. Another alternative is a clearinghouse to accept claim submissions. The Medicare crossover is yet another technology-based step that allows for electronic claim receipt from the Centers for Medicare and Medicaid Services. Fund administrators who are choosing PPO repricers should consider the range of electronic processing methods available, as well as discounts offered.
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Eliminating Coverage Barriers.
Ladd, Scott; HR Magazine; v55 no6 pp 41-43 Jun 2010; journal article

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Abstract : Starting in 2014, insurers will have to cover preexisting conditions under the Patient Protection and Affordable Care Act, and in 2011 for those under age 19. The majority of large firms already cover preexisting conditions, partly to manage conditions and avoid larger bills resulting from gaps in care. The Health Insurance Portability and Accountability Act defined conditions around existing illnesses, and value-based health benefits design has reinforced the advantages of making it as easy as possible to maintain benefits, promoting regular ongoing care for preexisting chronic illnesses such as diabetes and hypertension. Insurers may try to retain exclusions until forced by the law to drop them, but the inflow of funds from many Americans purchasing health insurance under the law may balance the cost of dropping the preexisting exclusion early.
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