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Your Ultimate Guide to HIPAA – Part One

HIPAA

Let me guess: You want your patients’ medical records handled with utmost care and security, don’t you? That is why you’re looking for a HIPAA compliant call center to partner with, so you can be confident that the way your customers’ medical records are handled is in accordance with the HIPAA guidelines. Of course, we can help you with just that since we are a HIPAA compliant call center.

However, in addition to supporting you through our services, we’d also like to bolster your current understanding of the act by educating you with the ins and outs of HIPAA.

We’re going to run a full-blown series talking about the guidelines and workings of HIPAA. At the end of the series, we hope that you’ll have a better understanding of how HIPAA works, so that you can stay compliant and avoid the hefty fees that comes with violating their rules.

Let’s hop right in.

HIPAA in a nutshell

If you didn’t already know, HIPAA is an acronym that stands for the Health Insurance Portability and Accountability Act of 1996.

It is an act that was enacted by the U.S. Congress on August 21, 1996, and was also signed by President Bill Clinton in the same year. It’s also known as the 191st Public Law of the 104th U.S. Congress.

Other names that it goes by is the Kassebaum–Kennedy Act or the Kennedy–Kassebaum Act, which is named after two of its main leading sponsors.

It’s official long title is: “An act to amend the Internal Revenue Code of 1986 to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use of medical savings accounts, to improve access to long-term care services and coverage, to simplify the administration of health insurance, and for other purposes.

The long title above mentions multiple actions that HIPAA covers. Parallel to the aforementioned enumerated processes that the act aims to accomplish, HIPAA is seen to be divided into a total of five different “titles” or parts in its table of contents, namely:

  • Title I: Health care access, portability, and renewability
  • Title II: Preventing health care fraud and abuse; administrative simplification; medical liability reform
  • Title III: Tax-related health provisions
  • Title IV: Application and enforcement of group health plan requirements, and
  • Title V: Revenue offsets

Let’s start this series by tackling the contents of each of these titles bit-by-bit. We are going to dive into each of these titles, and take a closer look at what each title is all about.

Up first is the healthcare title.

On health care access, portability, and renewability

The first title of HIPAA contains how the breadth and availability of some individual health insurance policies and group health plans are now regulated.

It amended acts such as the Public Health Service Act, the Employee Retirement Income Security Act, and the Internal Revenue Code.

Group health plan coverage and limitation

The first title requires that group health plans would cover individuals that have preexisting conditions. This title also limits the restrictions that a group health plan could place on the benefits for preexisting conditions.

The way it works is that group health plans could choose to refuse to provide benefits that are related to preexisting conditions for a term of 12 months after being enrolled in the plan or a period of 18 months in cases of late enrollment.

Title I also allows individuals to have the exclusion period of their group health-plan reduced depending on the amount of time of “creditable coverage” that they had right before enrolling in the plan. It also allows individuals this exclusion period reduction after “significant breaks” in coverage.

For a quick definition of these terms:

  • “Creditable coverage” has a broad definition, but includes almost all individual and group health plans, Medicaid, and Medicare.
  • “Significant breaks” in coverage is operationally defined as any 63-day time without any creditable coverage.

Title I comes with an exception though that allows employers to tie premiums and copayments to body mass index and tobacco use.

Another thing that the title requires is that policies ought to be issued without exception to individuals that are leaving group health plans with a creditable coverage that exceeds over 18 months.

This title also requires insurers to renew individuals regardless of health condition and without exclusion so long as these policies are being offered, or to provide alternatives instead to the plans that are discontinued so long as the insurer would stay in the market.

Exemptions on Title I requirements

Some health care plans are exempted from the Title I requirements as mentioned above.

Some of those that are exempted include long-term health plans and other plans that are limited in terms of scope, such as vision and dental plans that are often offered separately from general health plans.

However, if the general health plan includes the benefits mentioned above, then the HIPAA still applies to those kinds of benefits.

For example, if dental benefits are included in the new plan offer, then it has to count the creditable continuous coverage that is under the old health plan in determining any of the plan’s exclusion periods for dental benefits.

Alternate methods of calculating creditable coverage

Available as well to the health plans that are under Title I is an alternative method of calculating creditable continuous coverage.

There are categories of health coverage that can be considered separately, and these benefits, if offered separately, are not subjected to HIPAA requirements, such as:

  • Limited scope vision and dental benefits;
  • Nursing home care benefits;
  • Long-term care benefits;
  • Community-based care benefits;
  • Home health care benefits;
  • Any combination of the previous four benefits mentioned above, and;
  • Other similar limited benefits that are specified in regulations.

Anything that is not under the categories mentioned above has to use the general calculation.

A practical example for this would be to have the beneficiary counted with 18 months of the general coverage but only for six months of dental coverage because of how the beneficiary did not get a general health plan that was able to cover the dental plan up until six months before the application date.

Other features and concerns of Title I

There’s this odd case that exists in which applicants who enter into general group health plans cannot obtain certificates of continuous creditable coverage for independent limited-scope plans, so that they could use these certificates to apply towards the exclusion periods of the plan because of how the limited-coverage plans are exempted from HIPAA requirements.

Also, Title I does not allow the validity of hidden exclusion periods.

Clauses, such as “To be covered, the accident must have occurred while the stated beneficiary was covered under the same health-based insurance contract,” ought not to be acted upon and imposed by the health plan, and has to be re-written as to comply with HIPAA standards.

There is even more guidelines and details mentioned in Title I: Health Care Access, Portability, and Renewability of the Health Insurance Portability and Accountability Act of 1996.

However, despite all that we’ve tackled so far, we are still just scratching the surface as compared to all the contents that the first title of the act has to offer.

If you would like to read more on the contents of Title One, or if you would like to read more about the whole HIPAA itself, you could find the link to its official publication on the Government Publication Office website down in the Resource section below.

More about HIPAA soon

We are going to end the Part One of our series here. I hope that you’ve found value in what you’ve read so far.

For a teaser on the upcoming article, we are going to be continuing our extensive yet easy-to-read discussion on what HIPAA is all about and on why call centers have to be HIPAA compliant.

In the next article, we will be continuing with the next title in the list of titles under HIPAA, Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform.

We will be explaining what this second title of the act is all about, and we would also be going over significant topics under the title that are highly relevant towards getting closer to explaining why you need a HIPAA compliant call center.

A brief look into some of the topics under Title II that could be read in the upcoming article would include contents of the enforcement rule, the unique identifiers rule, the security rule, the transactions and code sets rule, and the privacy rule.

These are just some of the insights that you would be getting regarding the HIPAA in the next article.

So, stay tuned for Part Two of our Ultimate Guide to HIPAA.

(Note: If you’re looking for a HIPAA compliant call center to help you with administering your customer’s sensitive medical records. Contact us now.)

Resource

https://www.gpo.gov/fdsys/pkg/PLAW-104publ191/pdf/PLAW-104publ191.pdf

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