Group Insurance Health Care and the HIPAA Privacy Rule

HIPAA stands for Health Insurance Portability and Accountability Act. When I hear people talking about HIPAA, they are usually not talking about the original Act. They are talking about the Privacy Rule that was issued as a result of the HIPAA in the form of a Notice of Health Information Practices.

The United States Department of Health & Human Services official Summary of the HIPAA Privacy Rule is 25 pages long, and that is just a summary of the key elements. So as you can imagine, it covers a lot of ground. What I would like to offer you here is a summary of the basics of the Privacy Rule.

When it was enacted in 1996, the Privacy Rule established guidelines for the protection of individuals’s health information. The guidelines are written such that they make sure that an individual’s health records are protected while at the same time allowing needed information to be released in the course of providing health care and protecting the public’s health and well being. In other words, not just anyone can see a person’s health records. But, if you want someone such as a health provider to see your records, you can sign a release giving them access to your records.

So just what is your health information and where does it come from? Your health information is held or transmitted by health plans, health care clearinghouses, and health care providers. These are called covered entities in the wording of the rule.

These guidelines also apply to what are called business associates of any health plans, health care clearinghouses, and health care providers. Business associates are those entities that offer legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.

So, what does a typical Privacy Notice include?

  • The type of information collected by your health plan.
  • A description of what your health record/information includes.
  • A summary of your health information rights.
  • The responsibilities of the group health plan.

Let’s look at these one at a time:

Information Collected by Your Health Plan:

The group healthcare plan collects the following types of information in order to provide benefits:

Information that you provide to the plan to enroll in the plan, including personal information such as your address, telephone number, date of birth, and Social Security number.

Plan contributions and account balance information.

The fact that you are or have been enrolled in the plans.

Health-related information received from any of your physicians or other healthcare providers.

Information regarding your health status, including diagnosis and claims payment information.

Changes in plan enrollment (e.g., adding a participant or dropping a participant, adding or dropping a benefit.)

Payment of plan benefits.

Claims adjudication.

Case or medical management.

Other information about you that is necessary for us to provide you with health benefits.

Understanding Your Health Record/Information:

Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.

This information, often referred to as your health or medical record, serves as a:

Basis for planning your care and treatment.

Means of communication among the many health professionals who contribute to your care.

Legal document describing the care you received.

Means by which you or a third-party payer can verify that services billed were actually provided.

Tool in educating health professionals.

Source of data for medical research.

Source of information for public health officials charged with improving the health of the nation.

Source of data for facility planning and marketing.

Tool with which the plan sponsor can assess and continually work to improve the benefits offered by the group healthcare plan. Understanding what is in your record and how your health information is used helps you to:

Ensure its accuracy.

Better understand who, what, when, where, and why others may access your health information.

Make more informed decisions when authorizing disclosure to others.

Your Health Information Rights:

Although your health record is the physical property of the plan, the healthcare practitioner, or the facility that compiled it, the information belongs to you. You have the right to:

Request a restriction on otherwise permitted uses and disclosures of your information for treatment, payment, and healthcare operations purposes and disclosures to family members for care purposes.

Obtain a paper copy of this notice of information practices upon request, even if you agreed to receive the notice electronically.

Inspect and obtain a copy of your health records by making a written request to the plan privacy officer.

Amend your health record by making a written request to the plan privacy officer that includes a reason to support the request.

Obtain an accounting of disclosures of your health information made during the previous six years by making a written request to the plan privacy officer.

Request communications of your health information by alternative means or at alternative locations.

Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Group Health Plan Responsibilities:

The group healthcare plan is required to:

Maintain the privacy of your health information.

Provide you with this notice as to the planâEUR(TM)s legal duties and privacy practices with respect to information that is collected and maintained about you.

Abide by the terms of this notice.

Notify you if the plan is unable to agree to a requested restriction.

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. The plan will restrict access to personal information about you only to those individuals who need to know that information to manage the plan and its benefits. The plan will maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your personal information. Under the privacy standards, individuals with access to plan information are required to:

Safeguard and secure the confidential personal financial information and health information as required by law. The plan will only use or disclose your confidential health information without your authorization for purposes of treatment, payment, or healthcare operations. The plan will only disclose your confidential health information to the plan sponsor for plan administration purposes.

Limit the collection, disclosure, and use of participant’s healthcare information to the minimum necessary to administer the plan.

Permit only trained, authorized individuals to have access to confidential information.

Other items that may be addressed include:

Communication with family. Under the plan provisions, the company may disclose to an employee’s family member, guardian, or any other person you identify, health information relevant to that person’s involvement in your obtaining healthcare benefits or payment related to your healthcare benefits.

Notification. The plan may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, general condition, plan benefits, or plan enrollment.

Business associates. There are some services provided to the plan through business associates. Examples include accountants, attorneys, actuaries, medical consultants, and financial consultants, as well as those who provide managed care, quality assurance, claims processing, claims auditing, claims monitoring, rehabilitation, and copy services. When these services are contracted, it may be necessary to disclose your health information to our business associates in order for them to perform the job we have asked them to do. To protect employee’s health information, however, the company will require the business associate to appropriately safeguard this information.

Benefit coordination. The plan may disclose health information to the extent authorized by and to the extent necessary to comply with plan benefit coordination.

Workers compensation. The plan may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Law enforcement. The plan may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

Sale of business. If the plan sponsor’s business is being sold, then medical information may be disclosed. The plan reserves the right to change its practices and to make the new provisions effective for all protected health information it maintains. Should the company’s information practices change, it will mail a revised notice to the address supplied by each employee.

The plan will not use or disclose employee’s health information without their authorization, except as described in this notice.

In Summary:

As an employee, you should be aware of your rights and feel confident that your employer is abiding by the guidelines of the Privacy Rule.

As an employer offering group insurance health care benefits, you should make your employees aware of their rights and should give them an avenue to obtain more information or to report a problem.

When you get your health insurance coverage through a broker that specializes in employee benefits, they should provide you with all of the necessary information and Privacy Notice to make sure you comply with the HIPAA guidelines.

Maybe It’s Time We Re-Think The Health Insurance Model

Health Insurance premiums are a derivative of healthcare cost. The more healthcare costs the more it is to provide insurance. The richer the benefits package, the higher the premiums to enjoy those benefits.

In the United States of America we have some of the best healthcare in the world. The five year cancer survival rate for U.S. Women is 63% compared to 56% of European women. US men fair even better with a 66% survival rate versus 47% of European men. Better care is probably worth paying more for, but how much more.

Prior to the Patient Protection and Affordable Care Act (PPACA), each state governed it health laws. Some states had more requirements than others. An insurance mandate is a requirement that an insurance company must follow in that particular state, such as mental health coverage. If mental health coverage is mandated by the state, then all carriers must provide that coverage. There are over 2000 different mandates when counting both individual state and federal mandates. Although mandates continue to be added, many remain controversial. Patient advocates believe they help ensure adequate health coverage, while others complain that mandates increase the cost of healthcare and insurance. The Affordable Healthcare Act added many federally mandated benefits we now see in the cost of your premiums.

Traditional Health Insurance

Establishing the right health plan is an important part of the success of a business or school district. If you can reduce health insurance cost, you can use those funds elsewhere. With traditional, fully insured, health insurance your school district collects a premium. The premium is set by the insurance company and is fixed for a year. The only way it changes is if there is a reduction or an addition in the workforce. The health care plan pays claims based on the policy purchased. The insured is responsible for any deductible or co-pays.

The Affordable Care Act has changed the rules of the game. Now plans with a lot of mandates come with a higher price tag and higher-out-of pocket expenses. Recently, the El-Paso (Texas) independent school district has decided to petition the teachers’ retirement system to leave the state wide health insurance program due to rising cost to the district and the employees. Their rates have doubled since 2002 and now have the highest out-of-pocket maximum ($6350) allowed under the healthcare law.

Self-Funded Plans

With many school district budget constraints, maybe it is time to rethink how health benefits are delivered. A self-funded plan may be a way to gain control of your districts health care expenses. With a self funded plan you pay only for the health services your group actually uses.

The cost of a self-funded plan has fixed components similar to insurance premiums. These are fixed cost to the employee. The district might want to purchase an additional “Stop-Loss” policy. This plan will cap the district’s expenses at a certain amount then kick over to the insurance carrier. A large group of over 200 employees is often self insured up to $100,000 or maybe $500,000. Smaller groups of less than 200 employees often have the stop-loss set at between $50,000 and $100,000.

The district then basically pays claims from the premium collected rather than paying the insurer for assuming the financial risk. Some larger organizations may handle everything internally; however, most will have a third party administrator to oversee the plan. This would allow the school district to have the flexibility of the self funded plan without having to take on the management of the program.

When premiums are set by the employer, it has to take into account claims expenses, administration costs, as well as some variable costs. It also needs to take into account the premium for the stop-loss insurance. This cannot always be perfectly predicted during any given month. When starting a plan data from past years claims expenses should be collected.

Self-Funded Plans and the Affordable Care Act

One of the biggest advantages of a self-funded plan is cash flow. These plans are exempt from premium taxes in most states. There are many reforms from the ACA that do not apply to self funded plans. Beginning in 2014, all non-grandfathered individual and group plans were required to offer a comprehensive package of items and services known as the ten essential health benefits. The ACA identified, in broad terms, the 10 benefits that must be included in all plans. Self funded group insurance plans are not required to cover the ten essential benefits. Another exemption for self funded plans is the Health Insurance industry tax. This fee applies to fully insured plans and is paid by the insurance companies directly. This fee is passed on to the consumer. It is expected that this fee will add 4% to premiums in future years. Also self-funded plans only pay state taxes on the stop loss portion of the plan instead of the entire cost of the plan.

While introducing these expensive mandates to the individual and commercial health insurance marketplace, Congress decided not to disrupt the self-insurance market, and exempted self-funded arrangements from many of the ACA requirements.

The premiums collected should be placed in an account where they can gain interest from the bank until they are needed. Also if claims are less than expected, you can use this to build a “claims fund” cash reserve or refund a portion at year’s end. It would also give you the option of reducing premiums the following year. The money collected is only paid out when a claim actually occurs. Another advantage is you can customize your benefits and allow flexibility as to what you want to offer. This could depend on the district collective bargaining agreement as well.

The main disadvantage of a self- funded plan is the situation when claims are higher than expected. While you have the stop-loss that will keep you from paying excessive claims, if you did not collect enough in premium, you will be operating at a loss for a few months, or even a year. Most districts will benefit from self funding as long as they can make an accurate assessment of the cost they are likely to have and set rates accordingly.

While there are many advantages of moving toward a self funded type program, and most will benefit from this, one should not assume they will automatically save money right away. When deciding if this type of plan is right for your district you should look at current claims utilization, current cash flow, as well as the current health status of current employees. Different parts of the country tend to have their own health needs and characteristics. This is one reason that prior to the Affordable Care Act, health insurance was in the hands of the states.

In most cases, if self-funded plans are managed properly, both large and small school districts can reduce healthcare costs and put the saving back into the school.

How to Collect Free Health Insurance Quotes – Helpful Shopping Tips

The good health care nowadays is expensive. This is the main reason why you need reliable health insurance. In this way you will be able to afford regular health checks and adequate treatment. You and your family can only benefit from such an arrangement. The only problem is that the coverage plans are expensive. Thus, the best thing you can do is to shop around for free health insurance quotes.

Your main objective is to collect as many of these as possible. In this way you have a better chance of finding the most beneficial offer with the most affordable rates. The best way to shop for free health insurance quotes is to use the internet. You will get plenty of offers easily and quickly.

It is best not to look for insurance companies straight away. This is time consuming and often totally ineffective. You have to go to the website of a company that provides quotes from different insurer. You will simply need to enter your zip code or the state in which you live. Then you will be redirected to a list of insurers in your area. By following the links you will get directly to the pages on their websites

Then you have to fill in a short form with some personal details. This is necessary as this information will determine the costs you will have to incur when purchasing a coverage plan. You should not need any special help to fill in the form. You need to have a basic idea about your medical history and present condition. You may also have to enter similar details about your spouse and/or your children if you are looking for a family plan. You might want to remember some of these details in advance. In this way you will save time when requesting free health insurance quotes.

Generally, it is important for you to decide what type of insurance you need. You know best whether you need an individual or family plan. You can readily go for student health insurance if you have not completed your university education yet. It is often more difficult for the buyers to decide whether they actually need a short term plan or not. It is generally recommended to individuals in between jobs. It is also suitable for recent graduates who have not find a permanent position yet. However, these plans may not be beneficial for people on a very restricted budget.

Usually, you will not wait for more than a couple of minutes to get an offer from an insurance company. This is yet another reason why you should devote some time to shopping and collect as many quotes as possible. You should not hesitate to request offers from all insurers listed on the general directory website. You do not have research these companies one by one in advance as the quote providers have done this for you. Still, once you start comparing the different free health insurance quotes you should definitely look at the ratings of the different companies.