HIPAA & Affordable Care Act - Module A

Primary Purpose of HIPAA

To modernize medical records privacy protect personally identifiable information address coverage portability and cover pre-existing conditions.

HIPAA Newborn Maternity Benefit

Guarantees a 48-hour hospital stay for new mothers and babies after a regular delivery and 96 hours after a caesarean section.

HIPAA Mental Health Requirement

Expands coverage for mental illness by requiring similar coverage for the treatment of mental and physical conditions.

HIPAA Small Employer Rule

Small employers with 2 to 50 employees cannot be denied group health insurance coverage due to the poor health status of an employee.

Guaranteed Renewability for Employers

Insurers offering health plans in the small or large group market must renew or continue coverage at the option of the plan sponsor.

Guaranteed Renewability for Individuals

Federal and state laws do not allow insurers to refuse to renew an individual's health insurance policy because of their health status.

HIPAA Renewability Exceptions

A policy can be cancelled for nonpayment of premium committing fraud terminating the policy moving out of the service area or ending association membership.

ACA Application Mistake Rule

Insurers are not allowed to retroactively void a person's paid-up health insurance because of a small technical error or unintentional mistake.

Short-Term Policy Renewal Risk

Short-term policies are marketed as non-renewable and the buyer does not have the right to renew the policy when it expires even if they become ill.

HIPAA Privacy Rule Purpose

A set of federal standards designed to protect the privacy of patients' medical records and health information maintained by covered health plans.

HIPAA Privacy Rule Patient Rights

Gives patients the right to examine their records obtain a copy of their health records and request corrections.

HIPAA Omnibus Rule Update

Passed in January 2013 and changed the protection timeline of health information from indefinite to 50 years after death while increasing privacy violation penalties.

HIPAA Security Rule

Establishes national standards for securing electronic protected health information through administrative technical and physical safeguards.

HIPAA Breach Notification Rule

Requires covered entities and their business associates to make notifications regarding breaches of unsecured protected health information.

Preexisting Condition Definition

An exclusion that protected insurers against paying for health conditions that existed prior to an individual purchasing a policy.

ACA Preexisting Condition Rule

The Affordable Care Act completely eliminated the preexisting condition exclusion for ACA medical expense plans.

ACA Exchanges and SHOP

Creates state-based health insurance exchanges and Small Business Health Option Programs for individuals and small businesses with up to 100 employees.

Advance Premium Tax Credit (APTC)

A refundable tax credit provided by the ACA to eligible individuals with household incomes between 100% and 400% of the Federal Poverty Level.

APTC Benchmark Plan

Tax credits are calculated on a sliding scale so that no one pays more than a set percentage of their income for the second lowest cost silver plan.

APTC Eligibility Exclusions

APTC can be applied to individual health insurance policies other than catastrophic policies and cannot be used by individuals eligible for Medicare Medicaid CHIP or affordable employer plans.

ACA Cost-Sharing Subsidies

Subsidies provided to eligible individuals with household incomes between 100% and 250% of the Federal Poverty Level to reduce deductibles co-pays and out-of-pocket limits.

Actuarial Value (AV) Definition

The percentage of total average costs for benefits that a health insurance plan will cover.

Actuarial Value Example

If a plan has an actuarial value of 70% the insurer covers 70% of the costs and the insured is responsible for the remaining 30%.