hipaa: everything you need to know

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  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    By

    Larry Grudzien

    Attorney at Law

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    The Health Insurance Portability and Accountability Act (HIPAA) of 1996 applies to all group health plans: Including:

    Self-insured plans, Insured plans, and HMOs

    It applies to a number of areas: Pre-existing conditions

    Special enrollment periods

    Health Status and Genetic Information Nondiscrimination Rules

    Lifetime and Annual Dollar Limits; Prohibition on Rescissions

    Guaranteed-Availability and Guaranteed-Renewability Rules for Large Group, Small Group, and Bona Fide Association Plans

    New disclosure rules

    Wellness programs

    Privacy

    Introduction to HIPAA

  • HIPAA Portability and

    Nondiscrimination Rules

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    An employee welfare benefit plan to the extent that the plan provides medical care to employees or their dependents directly or through insurance, reimbursement or otherwise. - ERISA 733(a)1), PHSA 2791(a)(1)

    Automatic Exceptions: AD&D insurance, Disability income insurance, Liability insurance, Supplement to liability insurance. Workers compensation Auto medical payment insurance Credit only insurance, and Coverage for on-site medical clinics. Code 9831(b)-9832(c)(1), ERISA 732(b)-733(c), PHSA 2721(c)- 2791(c) (1)

    What is a HIPAA Group Health

    Plan?

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    What is the Health Coverage Certification requirement?

    Group health plans and employers offering group health insurance coverage must provide a certification of the period of creditable coverage under the plan, the coverage under any applicable COBRA continuation provision, and the waiting period (if any).

    Who must provide Certifications? Individuals covered by group health plans must receive them.

    Employers are responsible, unless relieved under written agreement.

    To whom and when? Each employee and dependent who loses coverage.

    Upon loss of coverage:

    Automatically when coverage ends. Automatically when COBRA coverage ends . Upon request for certification.

    Code 9801(e)(1)(A), ERISA 701(e)(1)(A), PHSA 2701(e)(1)(A)

    Health Coverage Certification

    Requirements

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Method of delivery? By first class mail to last known address, or

    By electronic means.

    Contents of the certification

    By writing or electronic media.

    Required information.

    Provided automatically - only the most recent information.

    Provided by request - Each period of coverage.

    Temp Treas, Reg, 9801-5T, DOL Reg. 2590.701-5, HHS Reg, 146.115(a)(2)

    Health Coverage Certification

    Requirements

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Plan Description Periods of prior coverage without regard to specific

    benefits.

    Other benefits will be provided upon request.

    Certification of Dependent Coverage

    Provided to employees and dependents.

    One certificate to an entire family - only the most recent. Information.

    No Certificate until coverage ends.

    Enforcement

    Plan administrator can be sued.

    Excise tax of $100 per day per violation.

    Health Coverage Certification

    Requirements

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Four important changes Define pre-existing condition.

    Do not exclude participation for more than 12 or 18 months.

    Reduce the duration of any exclusion by period of creditable coverage.

    No exclusion involving pregnancy, childbirth or adoption.

    Code 9801(a) & (b), ERISA 701(a) & (b), PHSA 2701(a) (b)

    Preexisting Condition

    Requirements and Notice

    Obligations

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Prior creditable coverage

    Preexisting condition exclusions are reduced for

    prior creditable coverage - day for day .

    What is prior creditable coverage?

    What is a significant break in coverage?

    Preexisting Condition

    Requirements and Notice

    Obligations

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Enforcement:

    IRS imposed penalty - $100 per day.

    DOL and plan participants may file suit to force

    compliance.

    Code 5000(b), ERISA 502(a)(3)

    Preexisting Condition

    Requirements and Notice

    Obligations

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Group health plans must:

    Allow employees and dependents to enroll mid-year .

    In three specified situations: Loss of other coverage,

    Acquisition of new dependent and

    Gain eligible for Medicaid or CHIP.

    Employees and beneficiaries subject to this right

    are not treated as late enrollees.

    Benefits of this special enrollment right.

    Code 9801(f), ERISA 701(f)(1), PHSA 2701(f)(1)

    Special Enrollment Rights

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Loss of other coverage:

    COBRA was exhausted; or

    Either lost eligibility for employer coverage or the

    employer contribution for coverage ceased.

    Must request enrollment within 30 days of loss.

    No requirement to elect COBRA.

    Code 9832(f), ERISA 701(f)(1), PHSA 2701(f)(1)

    Special Enrollment Rights

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Acquisition of new dependent because: Marriage; or

    Adoption, placement for adoption or birth.

    Employee has right to enroll self and new dependent.

    Must enroll within 30 days of event.

    Effective date of coverage.

    Notice requirements.

    Special rights for COBRA beneficiaries.

    Temp Treas. Reg. 54/9801-6T(b), DOL Reg. 2590.701-6(b), 45 CFR 146.117(b)

    Special Enrollment Rights

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Special enrollment rights are available if the employee or dependent becomes eligible for assistance, with respect to coverage under the

    plan through either a Medicaid plan under Title XIX of the Social

    Security Act, or the state children's health insurance program (CHIP)

    under Title XXI of the Social Security Act.

    The employee who is eligible, but not enrolled, for coverage under the terms of the plan (or a dependent of such an employee if the

    dependent is eligible, but not enrolled, for coverage under such terms)

    may enroll in the plan upon becoming eligible for state premium

    assistance subsidy if special enrollment is requested in a timely

    manner.

    If an employee or dependent becomes eligible for state premium assistance subsidy, a plan must allow for a period of at least 60 days

    for the employee to request coverage under the plan after such

    eligibility is determined.

    Special Enrollment Rights

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Group health plans must not discriminate based on an individuals health status in:

    Eligibility - initial, continuing or late enrollment.

    Premiums or Contributions - determining the

    amount.

    Code 9802, ERISA 702, PHSA 2702

    Health Status Discrimination

    Rules

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Prohibited Discrimination in Eligibility:

    Group Health Plan must not base eligibility rules on health status related factors, but may:

    Exclude coverage for particular benefits,

    Establish limitations or restrictions,

    Exclude coverage for participation in dangerous activities, and

    Not deny benefits for injury resulting from act of domestic violence or a medical condition.

    Temp Treas. Reg. 54.9802-1T(b), DOL Reg. 2590.702(b,) 45 CFR

    146.121(b)

    Health Status Discrimination

    Rules

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Prohibited Discrimination in Premiums/Contributions:

    Group Health Plan may not charge greater premiums or contributions among similarly situated employees, but:

    Insurers are not limited in amount they may charge for premiums,

    Plans may charge different amounts to different groups, and

    Plans may charge different amounts for employees and their dependents.

    Code 9802(b), ERISA 702(b), PHSA 2702(b)

    Health Status Discrimination

    Rules

  • Copyright 2014- Not to be reproduced without express permission of Benefit Express Services, LLC

    Prohibited Discrimination in Premiums/Contributions: Health Status Factors:

    Health status

    Medical condition

    Claims experie

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