Health Insurance and HIPAA

Health Insurance

Contract between policyholder and insurance agency

Insurance Benefits

Reimburse policyholder, help offset cost accrued from injury/illness

Beneficiary

Person designated by an insurance policy to receive benefits/funds

Dependents

Person eligible to be covered under your plan (Spouse, children, parents, family members, domestic partners)

Subscriber

Insured Person (Policyholder, recipient)

Premium

Cost of the coverage provided by an insurance company; monthly bill you pay to have insurance

Deductible

amount of money must be paid yearly before the policy benefits begin

Copayment

a FIXED amount you pay for a covered healthcare service (regardless if deductible is met)

Out of Pocket Maximum/Stop Loss Provision

Most one has to pay for covered services in a year. Once reached, health insurance covers 100% of covered care.

Coinsurance

% of the total cost for health care (After OOP met)

Managed care plan

Type of health care plan

Health Maintenance Organization (HMO)

Have own network of doctors, hospitals and other healthcare providers. Members must choose a PCP from a network of local healthcare providers. Best for people without chronic illness and do not visit the doctor often.

HMO Advantages

Offer lower monthly premiums and copays

HMO Disadvantages

Do not cover out-of-network care (except in emergencies)

Preferred Provider Organization (PPO)

May receive care from any provider (do not have to select a PCP). Best for people who want to choose their own PCP/specialist.

PPO Advantages

Receive care from any provider. Referrals are not needed for specialist.

PPO Disadvantage

Higher monthly premiums and copays.

Medicare

Law, Social Security Act, health insurance for 65 or older, End Stage Renal Disease (ESRD), ALS (Lou Gehrig’s Disease)

Medicaid

Law, Social Security Act, Joint federal and state program, for people with limited income and resources (low income, blind, disabled, under 65), offers nursing homes/personal care services

Cost Sharing

Children and pregnant woman are exempted from charges

Obamacare

Patient Protection and Affordable Care Act (ACA), law that governs what private insurance plans cover and how much they charge, ensures private health plans are available to all americans. Includes annual physical, blood draws, pregnancy check ups, birth control. For uninsured people who are citizens/non-citizens not covered by Medicare.

Who does HIPAA protect?

Individuals who lose/change jobs or with specific diseases/pre-existing conditions

Privacy Rule

Protects a patient’s personal and protected health information (PHI)

Privacy Rule entities

Healthcare providers, health plan, and healthcare clearinghouse

Privacy Rule Provisions

Patient’s right to access health information, requirement for obtaining consent before sharing information, and guidelines how information can be used and disclosed

PHI

name, address, birth date, SS number, biometric identifiers, patient’s past, present, future health conditions and the care and payment for the care provided

Security Rule

Protect electronic health information that can be held or transferable (electronic protected health information, e-PHI)