Fully-insured Plans

[Guest ro32]

Here's an interesting problem. If a company has a fully-insured plan and during enrollment, someone discloses certain medical information about themselves, how should the plan respond? I would presume that the mere fact that someone voluntary discloses medical information about themselves should not automatically require the plan to comply with all of hipaa's administrative requirements. And, if the the plan is using a broker, and the plan only gives enrollment information to the broker, which is still PHI, then then presumably the plan and the broker would have to enter into a business associate agreement.

Any thoughts?

[KIP KRAUS]

How does one disclose personal medical information during enrollment? Was it verbal, and to whom? There shouldn't be any reason to put such information on an enrollment form.

[mroberts]

If the group is under 50 or 100 lives, the enrollment form may include a detailed medical questionnaire. Some states allow an insurance company to then rerate the case based on the overall medical health of the group.

Regardless, even if that's not the case, strict interpretation of the new HIPAA regs require brokers to be treated as business associates. Chances are your broker has already signed an agreement with the insurance company that's handling your health insurance and this shouldn't be an issue.

[Guest DMK]

If an employer uses a third-party or broker to help faciliate enrollment in a fully-insured plan, my understanding is that this is a situation where the third-party or broker is performing a service for the employer, rather than the plan, and a business associate agreement is not needed. My understanding is that payroll services would fit into this category as well. What if the broker also receives information about enrollment/disenrollment in the fully-insured plan to help it provide consulting services to the employer?

I'm having some trouble, particularly in the fully-insured context, determining when a business associate agreement is needed or when the service is actually being provided to the employer and is not to, or on behalf of the plan. Can anyone enlighten me? Thanks.

[mroberts]

If the broker is solely helping in the enrollment, I might go along with that. But if the broker is also performing utilization reviews, administration, data analysis, monitoring the plan and performing marketings, my understanding is that he or she should should at least be entered into an agreement with the health insurance carrier. For self-insured arrangements, the broker would also need to be entered into an agreement with the client.