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. What is the rule imposed by HIPAA on a group health plan if the plan has both a waiting period and a preexisting-condition exclusion (PCE) period?
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For purposes of HIPAA, protected health information (PHI) is defined as
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HIPAA Rules
| Question | Answer |
|---|---|
| . What is the rule imposed by HIPAA on a group health plan if the plan has both a waiting period and a preexisting-condition exclusion (PCE) period? | The two periods must run concurrently. |
| For purposes of HIPAA, protected health information (PHI) is defined as | ) individually identifiable health information that is maintained by a covered enti |
| Coverage under a prior health plan is generally not considered creditable under HIPAA if there has been a break in coverage of at least | 63 days |
| Which of the following statements concerning business associate contracts under HIPAA is (are) correct? I. They are unnecessary if the business associates are attorneys or accountants. II. A covered entity is required to immediately terminate the contra | I is incorrect because business associate contracts are necessary whenever a covered entity uses a business associate. II is incorrect because a covered entity must take steps to end the violation. Only if this is unsuccessful must the entity terminate t |
| According to HIPPA the following which of the following is NOT discriminatory? | providing more favorable terms to participants with adverse health conditions |
| Which statement concerning HIPAA privacy is incorrect? | The sponsor of a fully insured group health plan is not exempt from the HIPAA privacy requirements. However, most of the requirements can be avoided as long as the plan is insured and the sponsor has no access to PHI other than summary health information |
| One objective of HIPAA is to standardize health care transactions. T/F | True |
| HIPAA portability requirements apply to group plans but not to the insurers who issue policies to the plans. | False |
| Disability income plans are subject to HIPAA. T/F | False. Disability income plans are exempt from HIPAA. |
| Violation of HIPAA rules may result in both civil and criminal penalties. T/F | True |
| A preexisting condition for purposes of HIPAA requires that an individual has either sought or received treatment for the condition within the prior 6 months. | True |
| The maximum preexisting-condition exclusion period allowed by HIPAA is 24 months. | False. As long as an individual enrolls in a plan when initially eligible, the maximum exclusion period is 12 months. An 18-month period is allowed for late enrollees. |
| HIPAA permits pregnancy to be treated as a preexisting condition. | False. HIPAA prohibits pregnancy from being treated as a preexisting condition. |
| A preexisting-condition exclusion period otherwise allowed by HIPAA must be fully eliminated if a plan member has 6 months or more of prior creditable coverage? T/F | False,Creditable coverage only reduces the exclusion period. For example, 8 months of creditable coverage would reduce a 12-month exclusion period to 4 months. |
| n order for a plan to impose a preexisting-condition exclusion, the plan must give written notice of the exclusion and terms, and an individual's right to demonstrate creditable coverage. T/F | True |
| Administrators of insured plans may delegate to insurers the obligation to issue certificates of creditable coverage? | True |
| One benefit of special enrollment rights under HIPAA is that all family members participate in the same provider network? | True |
| Coverage under HIPAA's special enrollment rights is effective on the date prior coverage ceases. | False. Coverage under HIPAA's special enrollment rights begins on the first day of the month after the plan receives the enrollment form |
| An employee who has elected COBRA continuation may exercise HIPAA's special enrollment rights under a spouse's plan at any time during the COBRA period | False. Once COBRA coverage is elected, the spouse cannot exercise special enrollment rights until the end of the full COBRA period. |
| HIPAA's special enrollment rights for new dependents apply only to dependent children | False. HIPAA's special enrollment rights for new dependents also apply to an employee and spouse upon marriage or the acquisition of a new child by birth, adoption, or placement for adoption. |
| Health plans must notify individuals of their special enrollment rights on or before the date they are initially given the opportunity to enroll in the plan. | True |
| HIPAA's special enrollment rights apply to dependents of persons receiving COBRA coverage | True |
| A special enrollment period is allowed for employees who declined coverage because they had other coverage which they subsequently lost. | True |
| A special enrollment period is allowed for those who gain eligibility for a premium assistance subsidy under a state's Medicaid plan or CHIP. | True |
| For purposes of HIPAA, participation in dangerous activities is a health status-related factor | True |
| HIPAA allows a group health plan to require late enrollees to show evidence of insurability | FalseFalse. HIPAA prohibits late enrollees from having to show evidence of insurability. However, they may have to wait until the next open enrollment period, and there can be a preexisting-exclusion period of 18 months. |
| HIPAA allows a group health plan to exclude specific conditions or diseases as long as the exclusions are not directed at individual participants based on health status-related factors. | True |
| HIPAA allows a group health plan to provide more favorable terms to participants with adverse health conditions. | True |
| Employers that sponsor health plans need to determine who is responsible for satisfying HIPAA's certification requirements. | True |
| Employers should make sure that their group health plans contain actively-at-work clauses. | False. Employers should eliminate active-at-work clauses. |
| A summary plan description must be amended to reflect changes to the plan document that are required by HIPAA | True |
| HIPAA's insurance market rules limit the circumstances under which insurers may decline to renew group coverage | True |
| Employers that sponsor health plans need to determine who is responsible for satisfying HIPAA's certification requirements. | True |
| Individual medical expense policies used as part of a group health plan are exempt from HIPAA requirements. | False |
| HIPAA privacy standards address how the rights of individuals to determine health information is used or disclosed | True |
| Because they must gather health information as part of the enrollment process, health plans are exempt from HIPAA's administrative simplification requirements. | False. Health plans are one of the types of entities that are subject to HIPAA's administrative simplification requirements. |
| HIPAA's privacy requirements apply only to health information transmitted electronically | False. HIPAA's privacy requirements apply to "individually" identifiable health information transmitted or maintained in any form or medium. |
| For purposes of HIPAA, the term health information includes premium payment information | True |
| Under HIPAA, all individually identifiable health information is protected health information | False. Individually identifiable health information is a broader term and may or may not be protected health information. |
| HIPAA preempts other federal laws relating to privacy | False. HIPAA does not preempt other federal laws and certain state laws relating to privacy, confidentiality, and security of health information. |
| The insurer of a group health plan may disclose health information on identifiable employees to a group health plan for purposes of obtaining premium bids | False. An insurer can release summarized information about claims history, expenses, and types of claims. However, names and certain other identifying information must be removed. |
| A group health plan may disclose PHI to plan sponsors for purposes of plan administrative functions as long as the plan sponsor agrees in the plan document to limitations on the use and disclosure of PHI. | True |
| ERISA may expose a group health plan or its fiduciaries to liability once HIPAA privacy and security obligations are included as part of the plan document. | True |
| A health plan may condition payment of a specific claim on provision of an authorization to disclose PHI if such disclosure is necessary to determine payment. | True |
| A covered entity that knows of a business associate's material violation of the business associate's contract must immediately terminate the contract. | Feedback: False. The covered entity must take reasonable steps to end the violation. If that is unsuccessful, the covered entity must terminate the contract or, if not feasible, report the business associate to the federal Department of Health and Human S |
| Under the minimum-necessary standard, a covered entity must develop criteria designed to limit the amount of PHI disclosed or requested | True |
| As long as specified conditions are satisfied, covered entities may disclose PHI without authorization for public policy purposes, such as judicial proceedings. | True |
| The HIPAA privacy standards prohibit covered entities from releasing PHI without authorization even if the information has been de-identified | False. Information that has been properly de-identified can be released without authorization. |
| HIPAA grants individuals the right to inspect and make a copy of their PH | True |
| HIPAA requires that a separate notice of privacy practices for PHI be provided to the spouse and each dependent of a covered employee. | False. A single notice to the covered employee is effective for all covered dependents under a health plan. |
| A fully insured health plan is required to provide a HIPAA privacy notice regardless of whether it has access to PHI. | False. As long as the plan has no access to PHI, except for summary health plan and enrollment information, the plan has no obligation to provide a notice. The notice requirement is imposed on the insurer only. |
| The HIPAA privacy standards require covered entities to train their workforces on privacy policies and procedures | True |
| plan sponsor is prohibited from providing employees with assistance in claim disputes unless it has access to PHI. | False. A plan sponsor is permitted to assist employees with claim disputes even if it has no access to PHI. |
| If a sponsor of an insured plan wishes to have access to PHI, the plan must obtain a certificate from the plan sponsor that the plan documents have been amended and a firewall put in place to protect the disclosure of PHI. | True |
| HIPAA privacy rules for self-funded plans are generally stricter if a plan has fewer than 50 participants | False. Self-funded and self-administered plans with fewer than 50 participants are not required to comply with certain HIPAA requirements |
| One purpose of the HIPAA core security requirements is to ensure the integrity and confidentiality of health information. | True |
| The HIPAA core security requirements apply only to nonelectronic PHI because the EDI standards protect PHI in electronic form. | False. The HIPAA core security requirements apply to electronic PHI. The EDI standards apply to standardized formats and content for covered electronic transactions |
| Covered transactions for purposes of the HIPAA EDI standards include health claim | True |
| The EDI standards of HIPAA also apply to transactions conducted solely by paper or telephon | False. Transactions that are solely by paper or telephone are not subject to the EDI standards. |
| Employers that sponsor health plans should review operations to identify the flow of PHI within and involving the plan, and any gaps between actual operations and HIPAA standards. | True |
| The sponsor of a fully insured group health plan is not exempt from the HIPAA privacy requirements. However, most of the reqmts can be avoided as long as the plan is insured & the sponsor has no access to PHI other than summary hlth info & enrollment info | |
| What is 4 Main Objectives of HIPAA? | 1. Improve portability of health coverage 2. Standardize health care transactions 3. Impose privacy & security requirements 4. Make other changes to health care delivery system. |
| What Plans are EXEMPT from HIPAA? | 1. Plans providing only incidental cvg. (accident, disability) 2.Workers Compensagion |
| What Entities MUST comply with HIPAA? | 1. The Group health plan itself (the sponsor) 2. the Insurer of the Plan |
| What type of Self Administered, Self Funded group health plan does not have to comply with HIPAA? | A group health plan self funded with fewer than 50 participants. |
| What is the maximum PCE period? | 12 months OR 18 months for late enrolee. |
| For purposes of PCE period what is the enrollment date? | The enrollment date is the date coverage begins OR if a waiting period , the 1st day of the waiting period |
| Under what circumstances does HIPAA limit the application of a preexisting-condition exclusion? | 1. Genetic information a alone w/out diagnosis of related condition 2.Pregnancy 3.Newborns or children under 19 |
| What must a plan do in order to impose a preexisting condition exclusion? | It must give WRITTEN notice in any application materials distributed by plan of the PCE's existence & terms & of individuals right to demonstrate credible coverage. |
| What requirements apply to the issuance of a Certificate of CC? | HIPAA requires group health PLANS & INSURERS to do: 1. Issue CCC to all individuals who lose regular or COBRA coverage 2. HIPAA certificate must be issued to any individual who requests it while covered by plan or w/in 2 years after losing coverage. |
| What are reasons employee may elect special enrollment rights under HIPAA? | 1. Economic benefit of group rates vs indiv. rates. 2.Economic benefit of dependent rates vs indiv. rates for depen. 3.having all depen on same plan as participant 4.Having all family members participate in same network |
| If a individual becomes eligible for premium assistance subsidy what HIPAA special enrollment rights exist? | Effective April 1, 2009, those persons eligible for premium assistance subsidy under states Medicare program must enroll within 60 days of eligibility. |
| For HIPAA what items are considered health status-related factors? | 1.Health status 2.Medical condition 3.claims experience 4.receipt of health care 5.medical history 6.genetic testing/info 7.evidence of insurability 8.disability |
| What types of benefit restrictions are permissible under HIPAA? | A plan may limit/exclude benes for 1.specific conditions or diseases 2.certain treatments or drugs that may be experimental or medically unnecessary 3.plan may provide different benefits for diff. groups of similarly situated employees. |
| What should be on a compliance check list for HIPAA's portability requirements with regard to Plan Design & Administration? | 1.Which plans subject to portability 2.Special enrollment & nondiscrim requirmts 3.Administ. costs of maintaining PCE's outweigh cost savings 4.Plan design chgs such as Waiting Periods 5.Confirmation that insurance cvg,HMO's,stop loss don't have exclusion |
| What items need to be on compliance check list for HIPAA's portability requirements with respect to The Plan Document? | 1.PCE's 2.Special Enrollments 3.Non discrimination rules 4.Claims Procedures |
| What items should be on compliance check list for HIPAA"s portability requirements with respect to Summary Plan Descriptions (SPD's) or other participant communications? | 1.SPD must be amended to reflect chgs to plan doc. 2.At time of enrollment, member must be notified of plans PCE limitations, offset of prior cvg,right to demo proof of cc. 3.IF plan has limited enroll. periods notice to be given 4.special enrollment r |
| What type of market RULES does HIPAA impose on INSURERS that provide group health coverage? | 1. Guaranteed Renew ability 2. Guaranteed Availability |
| What are the THREE components of HIPPA's Administration simplification requirements? | 1.Privacy Standards 2.Security Standards 3.Transaction Standards |
| What information is covered by Privacy standards? | Who is authorized to access information and how the information is to used or disclosed |
| What information is covered by Security Standards? | Address the ability to control access to information & protect it from unauthorized persons & from alteration,distraction or loss |
| What information is covered by Transaction Standards? | Promote the standardization of certain payment-related electronic transactions |
| To what extent can a group health plan share PHI w/a plan sponsor with respect to Summary Health Information? | 1.May disclose to plan sponsor, upon rqst for purposes of obtaining premium bids. 2.For providing health insurance coverage under grp plan 3.Modifying, amending or terming group health plan. |
| To what extent can a group health plan share PHI with a plan sponsor with respect to Plan Administrative functions? | A group health plan may disclose PHI to plan sponsors for plan admin functions such as quality assurance, claims processing or auditing |
| What extent can a group health plan share protected PHI with a plan sponsor with respect to Uses and Disclosures With Authorization? | Covered entities may use & disclose PHI with an individuals authorization for essentially ANY purpose specified in the authorization. |
| Under what circumstances do HIPAA's privacy requirements REQUIRE disclosure of PHI? | 1. To individuals who exercise their individual rights. 2.To the Dept of Health and Human Services in connection w/enforcement & compliance review actions. |
| What are the EXCEPTIONS to the use and disclosure rules? | 1.Pul |
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