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That is exactly the question the many experts and the IRDA raised a few years ago when discussing the issue of health insurance and the transfer of credits gained in a situation where a customer shifts from Health Insurer A to B. This intervention by the IRDA has now resulted in happy news for customers availing health insurance, especially those who are not satisfied with their existing insurer. Effective 01 October 2011, Health Insurance has become portable and you are now free to move to another provider and carry along all the credits gained for having been loyal. To get a better perspective of the whole idea of Portability we need to explore how things worked before 01/10/11. Let us say you were a customer, who, had a Health Insurance policy with ABC Company, and were not satisfied with their service. You approach company XYZ to transfer your policy and they would have said that you will be treated as a new policyholder. Meaning, all the benefits you had accrued by regularly paying your premium to the earlier insurer would stand nullified and you would need to build your loyalty from scratch. The IRDA defines portability as - "The right accorded to an individual health insurance policy holder (including family cover) to transfer the credit gained by the insured for preexisting conditions and time bound exclusions if policy holder plans to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break." From your perspective as a customer, you need to understand two major points from the above definition to realize how it applies to you. 1. 2. Pre-existing condition credit Time-bound exclusions
Pre-existing condition/disease Then- When one avails of a health insurance policy, he is not given any cover for claims arising out of a disease/condition he/she is ailing from, on the day of taking the claim. Nevertheless, if he/she continues as a regular premium payer for 4 years (48 months), then the insurance company will be bound to pay for claims arising out of the existing condition. In the past, if you shifted from one company to another, you were required to again do a premium paying term of 4 years to claim for PEDs. Now- With portability, you can carry forward credits gained for pre-existing disease/condition to the new insurer from day one itself. Time Exclusions Then- Time exclusions in a health insurance policy are certain illnesses for which no claims will be entertained for a set period from the date of taking the policy. For example, treatment of conditions/diseases like cataract, piles etc cannot be claimed in the first 365 days of taking
the policy. The reason for this is that these are treatments, which can be postponed for many days, and hence the insurance company could have individuals taking a policy just for claiming for such treatments. Such exclusions are called One-year exclusions, Two year exclusions and so on till four years. Now- In case you were covered under the existing insurance policy for a period of one year, the waiting period of 30 days and first year exclusions will not apply in policy to be renewed. The two-year exclusions shall apply for a period of one more year. Pre-existing condition exclusion shall apply for a period of three more years. Similarly will be the case with 2 year, 3 year and 4 year exclusions, where the period already spent with the earlier insurer will be credited to you. This also includes the 30 day mandatory waiting period. How do I port my health insurance? To transfer your policy from company A to company B, you will need to approach Company B (new insurer). You will be asked to fill in an application for porting. Company B will then process the application and post the request on the IRDA site within 7 days. The existing insurer (company A) will have to furnish all the required data about the insured within 7 days , again through the IRDA website. Once satisfactory data is available, Company B will underwrite your policy and you will be a customer of B and carry forward all benefits from company A. 5 things to remember before opting for porting 1. When applying for porting, be sure that your existing policy is valid for at least 45 days more. Else, the application will be rejected. 2. The portability is only applicable for the sum-insured under previous policy.
3. Portability is applicable for all individual health policies. In case you are a part of a family/group policy, you will need to migrate to an individual policy from the same insurer and then apply for portability only after 1 year. 4. Sometimes the waiting period/exclusion period for the same disease might be different for different insurers. Ensure that you are clear about all the terms and conditions before applying. 5. Do not port for saving money on premium. With the new competitive premium regime, the differences in premium of two companies will not be very high. It is not advisable to port just because the other company is offering a lesser premium. Port if you have a service problem with existing insurer. Else, remember that all said and done, you will have to build a 'new relationship" with the new service provider (Agent, claim officers, front office staff etc). And relationships take time to mature. You have been given the power to choose your provider. Get educated and take an informed decision. Stay healthy. Stay happy The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L. 104191, 110 Stat. 1936, enacted August 21, 1996) was enacted by the United States Congress and signed by President Bill Clinton in 1996. It was originally sponsored by Sen. Edward
Kennedy (D-Mass.) and Sen. Nancy Kassebaum (R-Kan.). Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II of HIPAA, 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.[1] The Administration Simplification provisions also address the security and privacy of health data. The standards are meant to improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in the U.S. health care system.
Contents
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1 Title I: Health Care Access, Portability, and Renewability 2 Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform o 2.1 Privacy Rule o 2.2 Transactions and Code Sets Rule o 2.3 Brief 5010 Transactions and Code Sets Rules Update Summary o 2.4 Security Rule o 2.5 Unique Identifiers Rule (National Provider Identifier) o 2.6 Enforcement Rule 3 HITECH Act: Privacy Requirements 4 Effects on research and clinical care o 4.1 Effects on research o 4.2 Effects on clinical care o 4.3 Costs of implementation 5 HIPAA and drug and alcohol rehabilitation organizations 6 Notable Violations 7 Legislative information 8 References 9 External links
individuals to reduce the exclusion period by the amount of time that they had "creditable coverage" prior to enrolling in the plan and after any "significant breaks" in coverage.[3] "Creditable coverage" is defined quite broadly and includes nearly all group and individual health plans, Medicare, and Medicaid.[4] A "significant break" in coverage is defined as any 63 day period without any creditable coverage.[5] Some health care plans are exempted from Title I requirements, such as long-term health plans and limited-scope plans such as dental or vision plans that are 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 it must count creditable continuous coverage under the old health plan 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. That is, 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 not valid under Title I (e.g., "The accident, to be covered, must have occurred while the beneficiary was covered under this exact same health insurance contract"). Such clauses must not be acted upon by the health plan and also must be rewritten so that they comply with HIPAA. To illustrate, suppose someone enrolls in a group health plan on January 1, 2006. This person had previously been insured from January 1, 2004 until February 1, 2005 and from August 1, 2005 until December 31, 2005. To determine how much coverage can be credited against the exclusion period in the new plan, start at the enrollment date and count backwards until you reach a significant break in coverage. So, the five months of coverage between August 1, 2005 and December 31, 2005 clearly counts against the exclusion period. But the period without insurance between February 1, 2005 and August 1, 2005 is greater than 63 days. Thus, this is a significant break in coverage, and any coverage prior to it cannot be deducted from the exclusion period. So, this person could deduct five months from his or her exclusion period, reducing the exclusion period to seven months. Hence, Title I requires that any preexisting condition begin to be covered on August 1.
[edit] Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform
This section needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (April 2010)
Title II of HIPAA defines numerous offenses relating to health care and sets civil and criminal penalties for them. It also creates several programs to control fraud and abuse within the health care system.[6][7][8] However, the most significant provisions of Title II are its Administrative Simplification rules. Title II requires the Department of Health and Human Services (HHS) to draft rules aimed at increasing 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, such as billing services and community health information systems, and health care providers that transmit health care data in a way that is regulated by HIPAA.[9][10] 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.
However, according to the Wall Street Journal, the OCR has a long backlog and ignores most complaints. "Complaints of privacy violations have been piling up at the Department of Health and Human Services. Between April of 2003 and November 2006, the agency fielded 23,886 complaints related to medical-privacy rules, but it has not yet taken any enforcement actions against hospitals, doctors, insurers or anyone else for rule violations. A spokesman for the agency says it has closed three-quarters of the complaints, typically because it found no violation or after it provided informal guidance to the parties involved."[26] However, in July 2011, UCLA agreed to pay $865,500 in a settlement regarding potential HIPAA violations. An HHS Office for Civil Rights investigation showed from 2005 to 2008 unauthorized employees, repeatedly and without legitimate cause, looked at the electronic protected health information of numerous UCLAHS patients.[27]
837 Health Care Claim: Professional standard to send in claims. As there are many different business applications for the Health Care claim, there can be slight derivations to cover off claims involving unique claims such as for Institutions, Professionals, Chiropractors, and Dentists etc. EDI Retail Pharmacy Claim Transaction (NCPDP Telecommunications Standard version 5.1) is used to submit retail pharmacy claims to payers by health care professionals who dispense medications, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit claims for retail pharmacy services and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of retail pharmacy services within the pharmacy health care/insurance industry segment. EDI Health Care Claim Payment/Advice Transaction Set (835) can be used to make a payment, send an Explanation of Benefits (EOB), send an Explanation of Payments (EOP) remittance advice, or make a payment and send an EOP remittance advice only from a health insurer to a health care provider either directly or via a financial institution. EDI Benefit Enrollment and Maintenance Set (834) can be used by employers, unions, government agencies, associations or insurance agencies to enroll members to a payer. The payer is a healthcare organization that pays claims, administers insurance or benefit or product. Examples of payers include an insurance company, health care professional (HMO), preferred provider organization (PPO), government agency (Medicaid, Medicare etc.) or any organization that may be contracted by one of these former groups. EDI Payroll Deducted and other group Premium Payment for Insurance Products (820) is a transaction set which can be used to make a premium payment for insurance products. It can be used to order a financial institution to make a payment to a payee. EDI Health Care Eligibility/Benefit Inquiry (270) is used to inquire about the health care benefits and eligibility associated with a subscriber or dependent. EDI Health Care Eligibility/Benefit Response (271) is used to respond to a request inquire about the health care benefits and eligibility associated with a subscriber or dependent. EDI Health Care Claim Status Request (276) This transaction set can be used by a provider, recipient of health care products or services or their authorized agent to request the status of a health care claim. EDI Health Care Claim Status Notification (277) This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient or authorized agent regarding the status of a health care claim or encounter, or to request additional information from the provider regarding a health care claim or encounter. This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set (835) and therefore, is not used for account payment posting. The notification is at a summary or service line detail level. The notification may be solicited or unsolicited. EDI Health Care Service Review Information (278) This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis
or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review. EDI Functional Acknowledgement Transaction Set (997) this transaction set can be used to define the control structures for a set of acknowledgments to indicate the results of the syntactical analysis of the electronically encoded documents. Although it is not specifically named in the HIPAA Legislation or Final Rule, it is necessary for X12 transaction set processing. The encoded documents are the transaction sets, which are grouped in functional groups, used in defining transactions for business data interchange. This standard does not cover the semantic meaning of the information encoded in the transaction sets.
[edit] Brief 5010 Transactions and Code Sets Rules Update Summary
1) Transaction Set (997) will be replaced by Transaction Set (999) "acknowledgement report". 2) The size of many fields {segment elements} will be expanded, causing a need for all IT providers to expand corresponding fields, element, files, GUI, paper media and databases. 3) Some segments have been removed from existing Transaction Sets. 4) Many segments have been added to existing Transaction Sets allowing greater tracking and reporting of cost and patient encounters. 5) Capacity to use both "International Classification of Diseases" versions 9 (ICD-9) and 10 (ICD-10-CM) has been added.
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Administrative Safeguards policies and procedures designed to clearly show how the entity will comply with the act o Covered entities (entities that must comply with HIPAA requirements) must adopt a written set of privacy procedures and designate a privacy officer to be responsible for developing and implementing all required policies and procedures. o The policies and procedures must reference management oversight and organizational buy-in to compliance with the documented security controls. o Procedures should clearly identify employees or classes of employees who will have access to electronic protected health information (EPHI). Access to EPHI must be
o o
restricted to only those employees who have a need for it to complete their job function. The procedures must address access authorization, establishment, modification, and termination. Entities must show that an appropriate ongoing training program regarding the handling of PHI is provided to employees performing health plan administrative functions. Covered entities that out-source some of their business processes to a third party must ensure that their vendors also have a framework in place to comply with HIPAA requirements. Companies typically gain this assurance through clauses in the contracts stating that the vendor will meet the same data protection requirements that apply to the covered entity. Care must be taken to determine if the vendor further outsources any data handling functions to other vendors and monitor whether appropriate contracts and controls are in place. A contingency plan should be in place for responding to emergencies. Covered entities are responsible for backing up their data and having disaster recovery procedures in place. The plan should document data priority and failure analysis, testing activities, and change control procedures. Internal audits play a key role in HIPAA compliance by reviewing operations with the goal of identifying potential security violations. Policies and procedures should specifically document the scope, frequency, and procedures of audits. Audits should be both routine and event-based. Procedures should document instructions for addressing and responding to security breaches that are identified either during the audit or the normal course of operations.
Physical Safeguards controlling physical access to protect against inappropriate access to protected data o Controls must govern the introduction and removal of hardware and software from the network. (When equipment is retired it must be disposed of properly to ensure that PHI is not compromised.) o Access to equipment containing health information should be carefully controlled and monitored. o Access to hardware and software must be limited to properly authorized individuals. o Required access controls consist of facility security plans, maintenance records, and visitor sign-in and escorts. o Policies are required to address proper workstation use. Workstations should be removed from high traffic areas and monitor screens should not be in direct view of the public. o If the covered entities utilize contractors or agents, they too must be fully trained on their physical access responsibilities. Technical Safeguards controlling access to computer systems and enabling covered entities to protect communications containing PHI transmitted electronically over open networks from being intercepted by anyone other than the intended recipient. o Information systems housing PHI must be protected from intrusion. When information flows over open networks, some form of encryption must be utilized. If closed systems/networks are utilized, existing access controls are considered sufficient and encryption is optional. o Each covered entity is responsible for ensuring that the data within its systems has not been changed or erased in an unauthorized manner.
o o
o o
Data corroboration, including the use of check sum, double-keying, message authentication, and digital signature may be used to ensure data integrity. Covered entities must also authenticate entities with which they communicate. Authentication consists of corroborating that an entity is who it claims to be. Examples of corroboration include: password systems, two or three-way handshakes, telephone callback, and token systems. Covered entities must make documentation of their HIPAA practices available to the government to determine compliance. In addition to policies and procedures and access records, information technology documentation should also include a written record of all configuration settings on the components of the network because these components are complex, configurable, and always changing. Documented risk analysis and risk management programs are required. Covered entities must carefully consider the risks of their operations as they implement systems to comply with the act. (The requirement of risk analysis and risk management implies that the acts security requirements are a minimum standard and places responsibility on covered entities to take all reasonable precautions necessary to prevent PHI from being used for non-health purposes.)
that HIPAA-mandated changes led to a 73% decrease in patient accrual, a tripling of time spent recruiting patients, and a tripling of mean recruitment costs.[39] In addition, informed consent forms for research studies now are required to include extensive detail on how the participant's protected health information will be kept private. While such information is important, the addition of a lengthy, legalistic section on privacy may make these already complex documents even less user-friendly for patients who are asked to read and sign them. These data suggest that the HIPAA privacy rule, as currently implemented, may be having negative impacts on the cost and quality of medical research. Dr. Kim Eagle, professor of internal medicine at the University of Michigan, was quoted in the Annals article as saying, "Privacy is important, but research is also important for improving care. We hope that we will figure this out and do it right."[37]
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- Extend health insurance portability - New insurer, same cover - Subir Roy: Pre-payment penalty
should go forthwith
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Even individual members, including the family members covered under group health insurance policy of a non-life insurer, will be able to migrate from a group health policy to an individual policy or a family floater with the same insurer. The scheme was proposed to come into force from July 1, but was deferred by three months due to certain outstanding issues with insurance companies. According to the new guidelines, consumers will get credit for the time already spent for covering pre-existing diseases, along with bonus accrued to them from their past insurers. Policyholders, however, will be able to carry over the waiting period with respect to pre-existing ailments. The waiting period for most pre-existing conditions is four years. For instance, if a person wants to shift after a year itself, the waiting period for the pre-existing ailment will be three years with the new insurer.
Health insurance portability has come in after a long wait. First lets see what it means before we delve into whom it will benefit and how. What it means Shyamal Banerjee/Mint Mobile number portability means that you can keep the same mobile number even as you switch the service provider. In health insurance it means that the period of time that you spend with your existing health insurance provider will be taken into account while working out the period of exclusions such as reimbursement of hospitalization expenses coming from pre-existing diseases or other temporary exclusions. For example, if the new health insurance company has a clause that they will not cover hospitalization expenses of knee replacement surgery within the first two years of the policy and you have had a policy for three years with your existing insurance company, then the new health insurance company will cover knee replacement
surgery expenses from the very first year of the policy with them. A pleasant surprise has been the right provided to the insured persons in group insurance policy to shift to an individual plan with the same insurance company that provided the group insurance policy. What it does not mean Just like mobile number portability, health insurance portability ensures that you have the option to shift to a new insurer with the same policy but it does not compel the new insurer to offer you the service. So if the new insurer refuses to provide the service, you will need to look at another provider or give up the idea of changing your service provider. Similarly, for health insurance, if you are already suffering from a serious disease, you are likely to find that portability is only a theoretical option as no other health insurance provider is willing to offer you its insurance policy. However, if you are part of a group insurance plan then the same insurance company cannot deny you the right to buy an individual plan from them. Who will benefit? The biggest beneficiaries of this will be employees who are falling out of a group insurance plan either due to retirement or resignation from a company. A lot of group insurance plans allow coverage of the parents of the employees, who otherwise find it difficult to get an insurance policy on their own. Retired employees also find it difficult to get a good health insurance plan. Now such employees can get a family floater plan from the same insurance company which cannot be refused. The other big beneficiaries will be young insured persons, who are healthy but are stuck with high-cost policies (think of companies which hiked premiums by 500% last year) or sub-optimal policies (which have very low sub-limits for room rents or other expenditure or require you to meet a large part of the eligible hospitalization expenditure yourselfcalled co-payment in insurance parlance). They can now shift to better policies that have no such restrictions and are reasonably priced. How will you benefit? Retiring people should make this application at least 60 days (the requirement is 45 days but it is better to be safe than be sorry) before their retirement date. Similarly, employees who are resigning need to make this application at least 45 days before they lose membership from the group plan due to the resignation (for resigning employees this has implications in terms of how soon will they let their employers know about their moving and whether their employer will give them the benefit of 45 days notice period). Regular consumers wishing to switch insurers should in any case make this application well in time before their existing policies expire. In all cases, consumers will need to submit the regular proposal form of the insurance company along with a portability form that is available at www.irda.gov.in/ADMINCMS/cms/Search_Results.aspx Please fully disclose all material facts that are relevant to the policy including any disease or claims made by you. This may result in the premium being higher or even the policy being denied. But it is far better to have an expensive policy or a policy that will actually pay the claim then to have a cheap policy where the claim is not paid. Who may not benefit When portability was thought about, the immediate beneficiary that came to our mind was the person who had a bad experience while getting his claim settled. Unfortunately, those consumers are unlikely to be welcomed by the new insurance company. The only saving grace here is the unexpected procedural benefit provided by the Insurance Regulatory and Development Authority (Irda), wherein the refusal has to be conveyed by the insurance company in writing within 15 days of receiving the proposal and all documents and information relating to the
portability proposal. So if you apply to any insurance company for portability plus an enhanced sum assured, then the company will need to respond back in writing or they will lose the right of refusal. In short, insurance companies will no longer be able to use inaction as a way to conveniently avoid taking on what they consider high-risk consumers. Unexpected effect Portability from group insurance policies was not envisaged when the subject was first being debated. Ironically, this benefit will ensure that group insurance policies will now be priced much higher and benefit for parents of employees are likely to be withdrawn or made prohibitively expensive since the company cannot refuse to issue an individual policy to the same family. Harsh Roongta is CEO, Apnapaisa.com. We welcome your comments at mintmoney@livemint.com