HIPPA (Health Insurance Portability and Accountability Act)

  • Health Insurance

With the growing use of paperless forms, electronic information transfers and storage has become the norm. This is true about our medical information as well. So, how do we know that our sensitive medical records are being kept private? Thanks to a federal law entitled Health Insurance Portability and Accountability Act (HIPAA), health plans, health care providers, and health care clearinghouses are required to abide by a set of standards to protect your data. While this law does offer protection for certain things, there are some companies that are not required to follow these standards. Keep reading to find out where the loopholes are and how you are being protected by this law. 

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What is the HIPAA Law and Privacy Rule?

Although HIPAA and Privacy and Security Rules have been around since 1996, there have been many revisions and changes over the years so to keep up with evolving health information technology. HIPAA and the HIPAA Privacy Rule set the bar for standards that protect sensitive patient information by making the rules for electronic exchange as well as the privacy and confidentiality of medical records and information by health care providers, health care clearing houses, and health plans. In accordance with HIPPA, Administrative Simplification Rules were created to safeguard patient privacy. This allows for information that is medically necessary to be shared while also maintaining the patient’s privacy rights. The majority of professionals in the health care industry are required to be compliant with the HIPAA regulations and rules. 

Why do we have the HIPAA Act and Privacy Rule?

The original goal of HIPAA was to make it easier for patients to keep up with their health insurance coverage. This is ultimately why the Administrative Simplification Rules were created to simplify administrative procedures and keep costs at a decent rate. Because of all the exchanges of medical information between insurance companies and health care providers, the HIPAA Act aims to keep things simple when it comes to the healthcare industry’s handling of patient records and documents and places a high importance on maintain patients’ protected health information. 

HIPAA Titles

The Health Insurance Portability and Accountability Act, a federal law which was designed to safeguard healthcare data from data breaches, has five titles. Here is a description of each title:

  • Title I: HIPAA Health Insurance Reform: The objective of Title I is to help individuals maintain health insurance coverage in the event that they lose or change jobs. It also prevents group health plans from rejecting applicants from being covered for having specific chronic illnesses or pre-existing conditions. 
  • Title II: HIPAA Administrative Simplification: Title II holds the U.S. Department of Health and Human Services (HHS) responsible for setting national standards for processing electronic healthcare transactions. In accordance with this title, healthcare organizations must implement data security for health data transactions and maintain HIPPA compliance with the rules set by HHS. 
  • Title III: HIPPA Tax-Related Health Provisions: This title is all about the national standards regarding tax-related provisions as well as the general rules and principles in relation to medical care.  
  • Title IV: Application and Enforcement of Group Health Plan Requirements: Title IV elaborates further on issues related to health insurance coverage and reform, one key point being for patients with pre-existing conditions. 
  • Title V: Revenue Offsets:  This title has provisions regarding company-owned life insurance policies as well as how to handle situations in which individuals lose their citizenship due to issues with income taxes. 

In day to day conversations, when you hear someone bring up HIPAA compliance, they are most likely referring to Title II. To become compliant with HIPAA Title II, the health care industry must follow these provisions:

  • National Provider Identifier Standard: Every healthcare entity is required to have a 10-digit national provider identifier number that is unique to them, otherwise known as, an NPI. 
  • Transactions and Code Sets Standard: Healthcare organizations are required to follow a set of standards pertaining to electronic data interchange (EDI) to be able to submit and process insurance claims.  
  • HIPAA Privacy Rule: This rule sets national standards that help to protect patient health information.
  • HIPAA Security Rule: This rule establishes the standards for patient data security. 

What information is protected by HIPAA?

The HIPAA Privacy Rule safeguards all individually identifiable health information obtained or transferred by a covered entity or business associate. Sometimes this information is stored or transmitted electronically, digitally, on paper or orally. Individually identifiable health information can also be referred to under the Privacy Rule as PHI. 

Examples of PHI are:

  • Personal identifying information such as the name, address, birth date and Social Security number of the patient. 
  • The mental or physical health condition of a person.
  • Certain Information regarding the payment for treatments.

HIPAA penalties

Health industries and professionals should take extra caution to prevent HIPAA violations. If a data breach occurs or if there is a failure to give patients access to their PHI, it could result in a fine. 

There are several types of HIPAA violations and penalties including:

  • Accidental HIPAA violations could result in $100 for an isolated incident and an upward of $25,000 for repeat offenses.
  • Situations in which there is reasonable cause for the HIPAA violation could result in a $1,000 fine and an upward of $100,000 annually for repeat violations.
  • Willfully neglecting HIPAA can cost anywhere between $10,000-$50,000 and $250,000-$1.5 million depending on whether or not it was an isolated occurrence, If it was corrected within a specific timeframe. 

The largest penalty one could receive for a HIPAA violation is $50,000 per violation and $1.5 million per year for repeated offenses.

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What Long-Term Care Insurance Covers

What Long-Term Care Insurance Covers – SmartAsset

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While Medicare and Medicaid both help aging adults afford some of their medical expenses, they may not cover the cost of an extended illness or disability. That’s where long-term care insurance comes into play. Long-term care insurance helps policyholders pay for their long-term care needs such as nursing home care. We’ll explain what long-term care insurance covers and whether or not such coverage is something you or your loved ones should consider.

Long-Term Care Insurance Explained

Long-term care insurance helps individuals pay for a variety of services. Most of these services do not include medical care. Coverage may include the cost of staying in a nursing home or assisted living facility, adult day care or in-home care. This includes nursing care, physical, occupational or speech therapy and help with day to day activities.

A long-term care insurance policy pays for the cost of care due to a chronic illness, a disability, or injury. It also provides an individual with the assistance they may require as a result of the general effects of aging. Primarily, though, long-term care insurance is designed to help pay for the costs of custodial and personal care, versus strictly medical care.

When You Should Consider Long-Term Care Insurance

During the financial planning process, it’s important to consider long-term care costs. This is important if you are close to retirement age. Unfortunately, if you wait too long to purchase coverage, it may be too late. Many applicants may not qualify if they already have a chronic illness or disability.

According to the U.S. Department of Health and Human Services, an adult turning 65 has a 70% chance of needing some form of long-term care. While only one-third of retirees may never need long-term care coverage, 20% may need it for five years or longer. With a private nursing home room averaging about $7,698 per month, long-term care could end up being a huge financial burden for you and your family.

Most health insurance policies won’t cover long-term care costs. Additionally, if you’re counting on Medicare to assist you with these extra expenses, you may be out of luck. Medicare doesn’t cover long-term care or custodial care. Most nursing homes classify under the custodial care category. This classification of care includes the supervision of your daily tasks.

So, if you don’t have long-term care insurance, you’re on the hook for these expenses. However, it’s possible to get help through Medicaid for low income families. But keep in mind, you may only receive coverage after you deplete your life savings. Just know that Medicare may cover short-term nursing care or hospice care, but little of the long-term care in between.

What Does Long Term Care Insurance Cover

So what does long term care insurance cover, Well, since the majority of long-term care policies are comprehensive policies, they may cover at-home care, adult day care, assisted living facilities (resident care or alternative care), and nursing home care. At home, long-term care may cover the cost of professional nursing care, occupational therapy, or rehabilitation. This may also include assistance with daily tasks, including bathing or brushing teeth.

Additionally, long-term care coverage can cover short-term hospice care for individuals who are terminally ill. The objective of hospice care is to help with pain management and provide emotional and physical support for all parties involved. Most policies allow beneficiaries to obtain care at a hospice facility, nursing home, or in the comfort of their own home. However, most hospice care is not considered long-term care and may receive coverage through Medicare.

Also, long-term care insurance can help cover the costs of respite care or temporary care. These policy extensions provide time off to those who care for an individual on a regular basis. Usually, respite care provides compensation to caregivers for 14 to 21 days a year. This care can take place at a nursing home, adult daytime care facility, or at home

What Long-Term Care Doesn’t Cover

If you have a pre-existing medical condition, you may not be eligible for long-term care during the exclusion period. The exclusion period can last for several months after your initial purchase of the policy. Also, if a family member provides in-home care, your policy may not pay them for their services.

Keep in mind, long-term care coverage won’t cover medical care costs. Many of your medical costs will fall under your coverage plan if you’re eligible for Medicare.

Long-Term Care Insurance Costs

Some of the following factors may affect the cost of your long-term care policy:

  • The age of the policyholder.
  • The maximum amount the policy will pay per year.
  • The maximum number of days the policy will pay.
  • The lifetime maximum amount that the policy will pay
  • Any additional options or benefits you choose.

If you’re in poor health or you’re currently receiving long-term care, you may not qualify for a plan. However, it’s possible to qualify for a limited amount of coverage with a higher premium rate. Some group policies don’t even require underwriting.

According to the American Association for Long-Term Care Insurance (AALTCI), a couple in their mid-50s can purchase a new long-term care policy for around $3,000 a year. The combined benefit of this plan would be roughly $770,000. Keep in mind, some policies limit your payout period. These payout limitations may be two to five years, while other policies may offer a lifetime benefit. This is an important consideration when finding the right policy.

Bottom Line

While it’s highly likely that you may need some form of long-term care, it’s wise to consider how you will pay for this additional cost as you age. While a long-term care policy is a viable option, there are alternatives you can consider.

One viable choice would be to boost your retirement savings to help compensate for long-term care costs. Ultimately, it comes down to what level of risk you’re comfortable with and how well a long-term care policy fits into your bigger financial picture.

Retirement Tips

  • If you’re unsure what long-term care might mean to your retirement plans, consider consulting a financial advisor. Finding the right financial advisor that fits your needs doesn’t have to be hard. SmartAsset’s free tool matches you with financial advisors in your area in 5 minutes. If you’re ready to be matched with local advisors that will help you achieve your financial goals, get started now.
  • The looming costs of long-term care may have you thinking about how much money you’ll need for retirement. If you aren’t sure how much your 401(k) or Social Security will factor into the equation, SmartAsset’s retirement guide can help you sort out the details.

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Ashley Chorpenning Ashley Chorpenning is an experienced financial writer currently serving as an investment and insurance expert at SmartAsset. In addition to being a contributing writer at SmartAsset, she writes for solo entrepreneurs as well as for Fortune 500 companies. Ashley is a finance graduate of the University of Cincinnati. When she isn’t helping people understand their finances, you may find Ashley cage diving with great whites or on safari in South Africa.
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A Guide to Coinsurance and Copays

A Guide to Coinsurance and Copays – SmartAsset

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Having health insurance makes it possible to receive medical care while only paying a fraction of that care’s true cost. Insurance doesn’t cover everything, however. Some of the cost of your care is still up to you to pay, and that cost comes in two primary forms: copays and coinsurance.

What Is a Copay?

A copay is a flat amount of money that you’re responsible for paying for a health care service. Copays typically apply for things like a doctor’s appointment, prescription drug or medical test. The amount of your copay is dependent on your specific health insurance plan.

You can typically expect to pay your copay when you check in for your service, be it an annual physical, dental cleaning or blood test. Copays are typically lower amounts ranging from $10 for something like a generic drug prescription to around $65 for a visit to a medical specialist.

Depending on your insurance plan, copays may not take effect until after you reach your deductible. Your deductible is the amount of money you must pay out-of-pocket before your insurance provider starts to pitch in. Deductibles reset at the beginning of every year.

When you are reviewing your plan information and you see the phrase “after deductible” or “deductible applies” in reference to your copays, that’s an indication that the copay is only in place once you meet your deductible. On the other hand, if you see “deductible waived,” that’s a sign that your copay is in place from the beginning. It may go without saying, but the latter situation is vastly preferable to you.

What Is Coinsurance?

Coinsurance is another method of splitting the cost of medical coverage with your insurance plan. A coinsurance is a percentage of the cost of services. You pay the percentage, and your insurance company foots the rest of the bill. So, if you have a $8,000 medical bill and a 20% coinsurance, you would be on the hook for $1,600.

Coinsurance typically only comes into play after you hit your deductible. Further, you may have differing coinsurance percentages for the same services depending on your provider network. If you have a preferred provider organization (PPO) plan, your coinsurance could be a higher percentage for providers outside your network than it is for providers in your network.

Similarly, your coinsurance may not apply to providers outside your network if you have a health maintenance organization (HMO) plan or an exclusive provider organization (EPO) plan. That’s because these plans typically don’t provide any out-of-network coverage.

Copay vs. Coinsurance

Copay and coinsurance are very similar terms. They both have to do with portions of the cost of your health care that’s under your responsibility. Because of that, and their similar names, it’s easy to confuse the two. There are a couple of important distinctions to keep in mind, however.

The most notable difference between copays and coinsurance is that copays are always a flat amount and coinsurance is always a percentage of the cost of the service. Another difference is that some copays can be in place before you hit your deductible, depending on the specifics of your plan. With coinsurance, you have to hit your deductible first.

Bottom Line

If you’re choosing between health insurance plans, make sure to examine the provided copays and coinsurance for each option. While they may not be the most important factor to consider, a high copay can be quite a pain, especially over the course of years of appointments and procedures.

Tips for Staying on Top of Medical Expenses

  • One of the best ways to stay ahead of surprise medical expenses is to have an emergency fund in place for just such a situation. If you can manage it, have three to six months worth of expenses stashed away in a high-yield savings account. That way, if you’re dealing with medical bills or have to step away from work, you’ll have a bit of a cushion.
  • If you’re not sure how an unexpected medical expenses would fit into your finances, consider working with a financial advisor to develop a financial plan. Finding the right financial advisor that fits your needs doesn’t have to be hard. SmartAsset’s free tool matches you with financial advisors in your area in 5 minutes. If you’re ready to be matched with local advisors that will help you achieve your financial goals, get started now.

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Hunter Kuffel, CEPF® Hunter Kuffel is a personal finance writer with expertise in savings, retirement and investing. Hunter is a Certified Educator in Personal Finance® (CEPF®) and a member of the Society for Advancing Business Editing and Writing. He graduated from the University of Notre Dame and currently lives in New York City.
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