Hippo: HIPAA Page
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A lot of regulation has followed passage of
the Health Insurance Portability and Accountability Act (HIPAA),
which has been called "one-third of the President's health care
The needle on the government's jargon meter
is about to bust with "Revised PRO Sanctions for Failing to Meet
Statutory Obligations," "Joint Interim Rules for Portability of Group
Health Plans," "Notification Procedures for States Implementing
'Alternative Mechanisms' in the Individual Market," and even
"Negotiated Rulemaking for the Shared Risk Exception."
If this kind of thing floats your boat,
grab a beverage and cozy up to the screen to read all about it. Then
get some help!
News, Reports &
- Federal Register
Program; Definition of Provider-Sponsored Organization and
Related Requirements[Federal Register: April 14, 1998
(Volume 63, Number 71)][Rules and Regulations] [Page
18124-18135] This interim final rule with comment period
defines the term ``provider-sponsored organization'' for
purposes of the Medicare program and establishes requirements
related to meeting this definition.
Care Programs: Fraud and Abuse; Revised OIG Civil Money
Penalties Resulting From the Health Insurance Portability and
Accountability Act of 1996 [Federal Register: March 25,
1998 (Volume 63, Number 57)] [Proposed Rules] [Page
14393-14402] This proposed rulemaking would codify new civil
monetary penalties (CMPs) for: Excluded individuals retaining
ownership or control interest in an entity; upcoding and claims
for medically unnecessary services; offering inducements to
beneficiaries; and false certification of eligibility for home
Program; Medicare Integrity Program, Intermediary and Carrier
Functions, and Conflict of Interest Requirements [Federal
Register: March 20, 1998 (Volume 63, Number 54)][Proposed
Rules] [Page 13590-13608] Would implement section 1893 of the
Social Security Act (the Act) by establishing the Medicare
integrity program (MIP) to carry out Medicare program integrity
activities that are funded from the Medicare Trust Funds.
of the OIG Compliance Program Guidance for Hospitals
[Federal Register: February 23, 1998 (Volume 63, Number
35)][Notices] [Page 8987-8998] Many providers and provider
organizations have expressed an interest in better protecting
their operations from fraud and abuse through the adoption of
voluntary compliance programs.
Coverage Requirements of Group Health Plans [Federal
Register: January 7, 1998 (Volume 63, Number 4)] [Proposed
Rules] [Page 708-712] The regulations will generally affect
sponsors of and participants in group health plans, and they
provide plan sponsors and plan administrators with guidance
necessary to comply with the law.
Long-Term Care Insurance Contracts [Federal Register:
January 2, 1998 (Volume 63, Number 1)][Proposed Rules] [Page
35-39] The regulations affect issuers of long-term care
insurance contracts and individuals entitled to receive
payments under these contracts. The regulations are necessary
to provide these taxpayers with guidance needed to comply with
Care Programs: Fraud and Abuse; Revised PRO Sanctions for
Failing To Meet Statutory Obligations, [Federal Register:
April 29, 1997 (Volume 62, Number 82)] [Rules and Regulations]
[Page 23140-23144]. This final rule addresses revised
procedures governing the imposition and adjudication of program
sanctions, based on recommendations from State utilization and
quality control peer review organizations (PROs), resulting
from enactment of sections 214 and 231(f) of the Health
Insurance Portability and Accountability Act (HIPAA) of 1996.
Interim Rules for Health Insurance Portability for Group Health
Plans [Federal Register: April 8, 1997 (Volume 62, Number
67)] [Rules and Regulations] [Page 16893-16976]. AGENCIES:
Internal Revenue Service, Department of the Treasury; Pension
and Welfare Benefits Administration, Department of Labor;
Health Care Financing Administration, Department of Health and
Human Services. ACTION: Interim rules with request for
Procedures for States Implementing ``Alternative Mechanisms''
in the Individual Health Insurance Market, [Federal
Register: January 13, 1997 (Volume 62, Number 8)] [Notices]
[Page 1768-1776]. This notice generally describes the statutory
provisions under section 111 of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) that
guarantee availability of individual health insurance coverage
to certain individuals with prior group coverage.
Care Programs, Fraud and Abuse; Intent To Form the Negotiated
Rulemaking Committee for the Shared Risk Exception,
[Federal Register: May 23, 1997 (Volume 62, Number 100)]
[Proposed Rules] [Page 28410-28413]. We have been
statutorily-mandated under section 216 of the Health Insurance
Portability and Accountability Act (HIPAA) of 1996, to
establish a negotiated rulemaking committee in accordance with
the Negotiated Rulemaking Act and the Federal Advisory
Committee Act (FACA).
and State Health Care Programs: Fraud and Abuse; Issuance of
Advisory Opinions by the OIG, [Federal Register: February
19, 1997 (Volume 62, Number 33)] [Rules and Regulations] [Page
7350-7360]. In accordance with section 205 of the Health
Insurance Portability and Accountability Act of 1996, this
final rule establishes a new part 1008 in 42 CFR chapter V to
address the new OIG advisory opinion process.
Market Health Insurance Reform: Portability From Group to
Individual Coverage; Federal Rules for Access in the Individual
Market; State Alternative Mechanisms to Federal Rules,
[Federal Register: April 8, 1997 (Volume 62, Number 67)] [Rules
and Regulations] [Page 16985-17004]. This interim final rule
with comment period implements section 111 of the Health
Insurance Portability and Accountability Act of 1996, which
sets forth Federal requirements designed to improve access to
the individual health insurance market.
- GAO Reports
Insurance Standards: New Federal Law Creates Challenges for
Consumers, Insurers, Regulators. HEHS-98-67. 30 pp. plus 6
appendices (18 pp.) February 25, 1998. Reviews the
implementation of the Health Insurance Portability and
Accountability Act (HIPAA), focusing on issues affecting: (1)
consumers; (2) issuers of health coverage, including employers
and insurance carriers; (3) state insurance regulators; and (4)
Insurance Portability: Reform Could Ensure Continued Coverage
for Up to 25 Million Americans (Letter Report, 09/19/95,
GAO/HEHS-95-257). Pursuant to a congressional request, GAO
provided information on: (1) the protections offered by current
state and federal health insurance portability reforms; (2) the
number of people who could be affected by broader national
portability standards; and (3) other issues related to the
design of national portability standards.
Insurance Regulation: Variation in Recent State Small Employer
Health Insurance Reforms (Fact Sheet, 06/12/95,
GAO/HEHS-95-161FS). Pursuant to a congressional request, GAO
provided information on state legislation to improve
portability, access, and rating practices for the
small-employer and individual health insurance markets.
- Health Hippo
STATEMENT BY DONNA E. SHALALA
- SECRETARY OF HEALTH AND HUMAN
- ON THE ANNIVERSARY OF THE HEALTH
INSURANCE PORTABILITY AND
- ACCOUNTABILITY ACT OF 1996
"This anniversary marks the enactment of landmark legislation that
has given millions of working people the comfort of knowing that if
they change jobs, they need not lose their health insurance. This is
an important step that demonstrates our commitment to improve access
to high-quality health care for all Americans.
"This legislation provides that a woman with a sick child can move
from one group plan to another without a lapse in health insurance,
and without paying more than other employees for coverage. And it
gives small businesses access to health insurance programs to provide
their employees with the coverage they need and deserve.
"In addition to providing health care portability, this
legislation created a stable source of funding for fraud control
activities, and giving us new resources to attack fraudulent health
care providers, and develop new management tools and techniques.
Funded by these critical resources, today I was pleased to award more
than $2.25 million in grants for new programs that will strengthen
our ongoing anti-fraud efforts."
HEALTH INSURANCE PORTABILITY AND
ACCOUNTABILITY ACT OF 1996 (Public Law 104-191 104th Congress)
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. <<NOTE: Aug. 21, 1996 - [H.R. 3103]>>
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled <<NOTE: Health
Insurance Portability and Accountability Act of 1996.>> ,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS <<NOTE: 42 USC
- (a) Short Title.--This Act may be cited as the "Health
Insurance Portability and Accountability Act of 1996''.
- (b) Table of Contents.--The table of contents of this Act is
CARE ACCESS, PORTABILITY, AND RENEWABILITY
- Subtitle A--Group Market Rules
- Part 1--Portability, Access, and Renewability Requirements
- Sec. 101. Through the
Employee Retirement Income Security Act of 1974.
- Part 7--Group Health Plan Portability, Access, and
- Sec. 701. Increased
portability through limitation on preexisting condition
- Sec. 702. Prohibiting
discrimination against individual participants and
beneficiaries based on health status.
- Sec. 703. Guaranteed
renewability in multiemployer plans and multiple employer
- Sec. 704. Preemption;
State flexibility; construction.
- Sec. 705. Special
rules relating to group health plans.
- Sec. 706.
- Sec. 707.
- Sec. 102. Through the
Public Health Service Act.
- TITLE XXVII--ASSURING PORTABILITY, AVAILABILITY, AND
RENEWABILITY OF HEALTH INSURANCE COVERAGE
- Part A--Group Market Reforms
- Subpart 1--Portability, Access, and Renewability Requirements
- Sec. 2701. Increased
portability through limitation on preexisting condition
- Sec. 2702.
Prohibiting discrimination against individual participants and
beneficiaries based on health status.
- Subpart 2--Provisions Applicable Only to Health Insurance
- Sec. 2711. Guaranteed
availability of coverage for employers in the group market.
- Sec. 2712. Guaranteed
renewability of coverage for employers in the group market.
- Sec. 2713. Disclosure
- Subpart 3--Exclusion of Plans; Enforcement; Preemption
- Part C--Definitions; Miscellaneous Provisions
- Subtitle B--Individual Market Rules
- Sec. 111. Amendment
to Public Health Service Act.
- Part B--Individual Market Rules
- Sec. 2741. Guaranteed
availability of individual health insurance coverage to certain
individuals with prior group coverage.
- Sec. 2742. Guaranteed
renewability of individual health insurance coverage.
- Sec. 2743.
Certification of coverage.
- Sec. 2744. State
flexibility in individual market reforms.
- Sec. 2745.
- Sec. 2746.
- Sec. 2747. "General
- Subtitle C--General and Miscellaneous Provisions
- Sec. 191. Health
coverage availability studies.
- Sec. 192. Report on
Medicare reimbursement of telemedicine.
- Sec. 193. Allowing
federally-qualified HMOs to offer high deductible plans.
- Sec. 194. Volunteer
services provided by health professionals at free clinics.
- Sec. 195. Findings;
II--PREVENTING HEALTH CARE FRAUD AND ABUSE; ADMINISTRATIVE
SIMPLIFICATION; MEDICAL LIABILITY REFORM
- Subtitle A--Fraud and Abuse Control Program
- Sec. 201. Fraud and
abuse control program.
- Sec. 202. Medicare
- Sec. 203. Beneficiary
- Sec. 204. Application
of certain health antifraud and abuse sanctions to fraud and
abuse against Federal health care programs.
- Sec. 205. Guidance
regarding application of health care fraud and abuse sanctions.
- Subtitle B--Revisions to Current Sanctions for Fraud and Abuse
- Sec. 211. Mandatory
exclusion from participation in Medicare and State health care
- Sec. 212.
Establishment of minimum period of exclusion for certain
individuals and entities subject to permissive exclusion from
Medicare and State health care programs.
- Sec. 213. Permissive
exclusion of individuals with ownership or control interest in
- Sec. 214. Sanctions
against practitioners and persons for failure to comply with
- Sec. 215.
Intermediate sanctions for Medicare health maintenance
- Sec. 216. Additional
exception to anti-kickback penalties for risk- sharing
- Sec. 217. Criminal
penalty for fraudulent disposition of assets in order to obtain
- Sec. 218. Effective
- Subtitle C--Data Collection
- Sec. 221.
Establishment of the health care fraud and abuse data
- Subtitle D--Civil Monetary Penalties
- Sec. 231. Social
Security Act civil monetary penalties.
- Sec. 232. Penalty for
false certification for home health services.
- Subtitle E--Revisions to Criminal Law
- Sec. 241. Definitions
relating to Federal health care offense.
- Sec. 242. Health care
- Sec. 243. Theft or
- Sec. 244. False
- Sec. 245. Obstruction
of criminal investigations of health care offenses.
- Sec. 246. Laundering
of monetary instruments.
- Sec. 247. Injunctive
relief relating to health care offenses.
- Sec. 248. Authorized
investigative demand procedures.
- Sec. 249. Forfeitures
for Federal health care offenses.
- Sec. 250. Relation to
- Subtitle F--Administrative Simplification
- Part C--Administrative Simplification
- Sec. 1171.
- Sec. 1172. General
requirements for adoption of standards.
- Sec. 1173. Standards
for information transactions and data elements.
- Sec. 1174. Timetables
for adoption of standards.
- Sec. 1175.
- Sec. 1176. General
penalty for failure to comply with requirements and standards.
- Sec. 1177. Wrongful
disclosure of individually identifiable health information.
- Sec. 1178. Effect on
- Sec. 1179. Processing
- Sec. 263. Changes in
membership and duties of National Committee on Vital and Health
- Sec. 264.
Recommendations with respect to privacy of certain health
- Subtitle G--Duplication and Coordination of
- Sec. 271. Duplication
and coordination of Medicare-related plans.
III--TAX-RELATED HEALTH PROVISIONS
- Subtitle A--Medical Savings Accounts
- Subtitle B--Increase in Deduction for Health Insurance Costs
of Self- Employed Individuals
- Sec. 311. Increase in
deduction for health insurance costs of self- employed indi-
- Subtitle C--Long-Term Care Services and Contracts
- Part I--General Provisions
- Sec. 321. Treatment
of long-term care insurance.
- Sec. 322. Qualified
long-term care services treated as medical care.
- Sec. 323. Reporting
- Part II--Consumer Protection Provisions
- Sec. 325. Policy
- Sec. 326.
Requirements for issuers of qualified long-term care insurance
- Sec. 327. Effective
- Subtitle D--Treatment of Accelerated Death Benefits
- Sec. 331. Treatment
of accelerated death benefits by recipient.
- Sec. 332. Tax
treatment of companies issuing qualified accelerated death
- Subtitle E--State Insurance Pools
- Sec. 341. Exemption
from income tax for State-sponsored organizations providing
health coverage for high-risk individuals.
- Sec. 342. Exemption
from income tax for State-sponsored workmen's compensation
- Subtitle F--Organizations Subject to Section 833
- Sec. 351.
Organizations subject to section 833.
- Subtitle G--IRA Distributions to the Unemployed
- Sec. 361.
Distributions from certain plans may be used without additional
tax to pay financially devastating medical expenses.
- Subtitle H--Organ and Tissue Donation Information Included
With Income Tax Refund Payments
- Sec. 371. Organ and
tissue donation information included with income tax refund
IV--APPLICATION AND ENFORCEMENT OF GROUP HEALTH PLAN REQUIREMENTS
- Subtitle A--Application and Enforcement of Group Health Plan
- Sec. 401. Group
health plan portability, access, and renewability requirements.
- Sec. 402. Penalty on
failure to meet certain group health plan requirements.
- Subtitle B--Clarification of Certain Continuation Coverage
- Subtitle A--Company-Owned Life Insurance
- Sec. 501. Denial of
deduction for interest on loans with respect to company-owned
- Subtitle B--Treatment of Individuals Who Lose United States
- Sec. 511. Revision of
income, estate, and gift taxes on individuals who lose United
- Sec. 512. Information
on individuals losing United States citizenship.
- Sec. 513. Report on
tax compliance by United States citizens and residents living
- Subtitle C--Repeal of Financial Institution Transition Rule to
Interest Allocation Rules
- Sec. 521. Repeal of
financial institution transition rule to interest allocation
- LEGISLATIVE HISTORY
HippoQuiz: Health Insurance Portability and
- Question: How many words and lines
are in the Health Insurance Portability and Accountability Act?
- Answer: About 73,840 words, 5704
lines (Source: MS WORD: Word Count)
- Question: How many sections are
missing from the THOMAS links to the Health Insurance
Portability and Accountability Act?
3103, Health Insurance Portability
At least three, including links to the new safe harbor
provisions, the new criminal penalties for medical
assistance transfers and the new law relating to volunteer
services provided by health professionals at free
- Question: When was the law signed by
- Question: How many titles make up the
new law (not counting the short title)?
- Access to Health Care
- Question: What is a "preexisting
condition" under the new law?
701 "A condition (whether physical
or mental), regardless of the cause of the condition, for
which medical advice, diagnosis, care, or treatment was
recommended or received within the 6-month period ending on
the enrollment date."
- Question: How long may a person be
denied health insurance coverage for a preexisting
701 12 months (or 18 months for a
- Question: How is genetic information
treated under the law?
702 "Genetic information shall not
be treated as a condition ... in the absence of a diagnosis
of the condition related to such information."
- Question: Are states free to
implement alternative health reform schemes?
- Answer: Yes, upon application and
with many restrictions. See
2744, 42 USC 300gg-44
- Question: Every new law has to
require a study. What is the Secretary of Health and Human
Services supposed to study?
- Answer: 1) Effectiveness of
reforms, and; 2) Impact on access and choice.
191 In addition, HCFA is to
complete its study on Medicare reimbursement for
- Fraud & Abuse
- Question: What are the primary
activities to be conducted by DHHS under the Medicare Integrity
202 (1) Review of activities of
individuals and entities furnishing items and services
including medical and utilization review and fraud review;
(2) Audit of cost reports; (3) Determinations as to whether
payment should not be, or should not have been, made and
recovery of payments that should not have been made; (4)
Education of providers of services, beneficiaries, and other
persons with respect to payment integrity and benefit
quality assurance issues, and; (5) Developing (and
periodically updating) a list of items of durable medical
equipment which are subject to prior authorization under
- Question: Can individuals be paid for
reporting health care fraud or suggestions that result in
203 Yes. Payments may be made at
the Secretary's discretion.
- Question: Will the Secretary accept
suggestions for new fraud and abuse safe harbors?
203 Of course. The Secretary will
annually request proposals for new safe harbors, which will
be evaluated based on their impact on: (A) access to health
care services; (B) quality of health care services; (C)
patient freedom of choice; (D) competition among health care
providers; (E) medically underserved areas or to medically
underserved populations; (F) cost to Federal health care
programs; (G) overutilization of health care services; (H)
financial benefit to a health care professional or provider
(I) Any other factors the Secretary deems appropriate. The
Secretary, in consultation with the Attorney General, may
issue advisory opinions on what constitutes fraud and abuse
and may continue to issue "Special Fraud Alerts."
- Question: Can risk-bearing
individuals and entities be subject to penalties under the
216 Sure, but a new exception
exists for "any remuneration between an organization and an
individual or entity providing items or services, or a
combination thereof, pursuant to a written agreement between
the organization and the individual or entity if the
organization is an eligible organization under section 1876
or if the written agreement, through a risk-sharing
arrangement, places the individual or entity at substantial
financial risk for the cost or utilization of the items or
services, or a combination thereof, which the individual or
entity is obligated to provide" and expedited rules will be
issued using a negotiated rulemaking process.
- Question: What is the legal standard
for conviction of health fraud as a result of transferal assets
to obtain eligibility for medical assistance?
217 "[K]knowingly and willfully
dispos[ing] of assets (including by any transfer in trust)
in order for an individual to become eligible for medical
assistance under a State plan under title XIX, if disposing
of the assets results in the imposition of a period of
ineligibility for such assistance." 42 U.S.C.
- Question: Will the National
Practitioner Data Bank be opened to the public?
221 Not yet, but the Secretary
will establish a new Fraud & Abuse Data Bank with
similar restrictions on public access.
- Question: What was the effective date
of these the new fraud provisions?
218 Many of the provisions were
effective on enactment, others were effective January 1,
- Question: How much is being spent to
beef up health care fraud and abuse enforcement?
201 The administration and
operation of the health care fraud and abuse control program
includes the costs of-- (i) prosecuting health care matters
(through criminal, civil, and administrative proceedings);
(ii) investigations; (iii) financial and performance audits
of health care programs and operations; (iv) inspections and
other evaluations; and (v) provider and consumer education.
The FBI is appropriated $434 million to the year 2002 for
this program. DHHS and the Attorney General are appropriated
$104 million in 1997, with increases of 15% until the year
2003. Approximately 60-70% of the DHHS appropriations go
directly to the Office of the Inspector General.
- Tax-Related Provisions
- Question: Did Medical Savings
Accounts make it into the law?
- Answer: Yes. The new laws relating
to Medical Savings Accounts can be found at
- Question: Will there be a tax-break
for long-term care insurance or services?
- Answer: Long-term care insurance
will be treated like health and accident insurance,
321, and long-term care services
will be treated as medical care for tax purposes.
- Question: What is the tax treatment
of viatical settlements?
- Answer: Viatical settlements for
terminally ill individuals will be treated the same as
insurance payments made on the death of the insured.
331 Qualified accelerated death
benefit riders will be treated as life insurance.
- Question: Is there a way to make the
public aware of the critical need for organ and tissue
371 Information on organ and
tissue donations will be included with all income tax refund
payments under the new law.
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