The Health Insurance Portability and Accountability Act of 1996 (HIPAA or the Kennedy–Kassebaum Act) is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1996. It aimed to alter the transfer of healthcare information and stipulated guidelines by which personally identifiable information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and addressed some limitations on healthcare insurance coverage. It generally prohibits healthcare providers and businesses called covered entities from disclosing protected information to anyone other than a patient and the patient's authorized representatives without their consent. The law does not restrict patients from accessing their own information, except in limited cases. Furthermore, it does not prohibit patients from voluntarily sharing their health information however they choose, nor does it require confidentiality where a patient discloses medical information to family members, friends, or other individuals not employees of a covered entity. The act consists of five titles:
Title I protects health insurance coverage for workers and their families if they change or lose their jobs. Title II, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. Title III sets guidelines for pre-tax medical spending accounts. Title IV sets guidelines for group health plans. Title V governs company-owned life insurance policies.
Titles There are five sections to the act, known as titles.
Title I: Health Care Access, Portability, and Renewability Title I of HIPAA regulates the availability and breadth of group health plans and certain individual health insurance policies. It amended the Employee Retirement Income Security Act, the Public Health Service Act, and the Internal Revenue Code. Title I also addresses the issue of "job lock," where employees remain in a job to avoid losing health coverage. To combat the job lock issue, the Title protects health insurance coverage for workers and their families if they lose or change their jobs. Title I requires the coverage of and limits restrictions that a group health plan can place on benefits for preexisting conditions. Group health plans may refuse to provide benefits in relation to preexisting conditions for either 12 months following enrollment in the plan or 18 months in the case of late enrollment. Title I allows individuals to reduce the exclusion period by the amount of time they have had "creditable coverage" before enrolling in the plan and after any "significant breaks" in coverage. "Creditable coverage" includes nearly all group and individual health plans, Medicare, and Medicaid. A "significant break" in coverage is defined as any 63-day period without any creditable coverage. Along with an exception, it allows employers to tie premiums or co-payments to tobacco use or body mass index (BMI). Title I mandates that insurance providers issue policies without exclusions to individuals leaving group health plans, provided they have maintained continuous, creditable coverage (see above) exceeding 18 months, and renew individual policies for as long as they are offered or provide alternatives to discontinued plans for as long as the insurer stays in the market without exclusion regardless of health condition. Some health care plans are exempted from Title I requirements, such as long-term health plans and limited-scope plans like dental or vision plans offered separately from the general health plan. However, if such benefits are part of the general health plan, then HIPAA still applies to such benefits. For example, if the new plan offers dental benefits, then creditable continuous coverage under the old health plan must be counted towards any of its exclusion periods for dental benefits. An alternate method of calculating creditable continuous coverage is available to the health plan under Title I. 5 categories of health coverage can be considered separately, including dental and vision coverage. Anything not under those 5 categories must use the general calculation (e.g., the beneficiary may be counted with 18 months of general coverage but only 6 months of dental coverage because the beneficiary did not have a general health plan that covered dental until 6 months prior to the application date). Since limited-coverage plans are exempt from HIPAA requirements, the odd case exists in which the applicant to a general group health plan cannot obtain certificates of creditable continuous coverage for independent limited-scope plans, such as dental, to apply towards exclusion periods of the new plan that does include those coverages. Hidden exclusion periods are invalid under Title I. For example: ‘The accident must have occurred while the beneficiary was covered under this same health insurance contract. Such clauses must not be acted upon by the health plan. Also, they must be re-written to comply with HIPAA.
Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform
Title II of HIPAA establishes policies and procedures for maintaining the privacy and the security of individually identifiable health information, outlines numerous offenses relating to health care, and establishes civil and criminal penalties for violations. It also creates several programs to control fraud and abuse within the health care system. The most significant provisions of Title II are the Administrative Simplification rules. Title II requires the Department of Health and Human Services (HHS) to increase the efficiency of the health-care system by creating standards for the use and dissemination of health care information. These rules apply to "covered entities" as defined by HIPAA and the HHS. Covered entities include health plans, health care clearinghouses (e.g., billing services and community health information systems), and health care providers that transmit health care data in a way regulated by HIPAA. Per the requirements of Title II, the HHS has promulgated five rules regarding Administrative Simplification: the Privacy Rule, the Transactions and Code Sets Rule, the Security Rule, the Unique Identifiers Rule, and the Enforcement Rule.
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