HEALTH PLAN IDENTIFIER NUMBERS (HPIDs)

Transcription

1 HEALTH PLAN IDENTIFIER NUMBERS (HPIDs) NEWLY REQUIRED HEALTH PLAN IDENTIFIER NUMBER (HPID) FOR SELF-FUNDED GROUP HEALTH PLANS 2014 SELF-FUNDED HEALTH PLANS MUST APPLY FOR A HEALTH PLAN IDENTIFIER (HPID) BY NOVEMBER 5,2014 (OR NOVEMBER 5, 2015, DEPENDING ON PLAN SIZE) SUMMARY Emplyers spnsring self-funded health plans are required t apply fr a Health Plan Identifier Number (HPID) frm the Centers fr Medicaid and Medicare Services (CMS). CMS has established a website fr registratin and issued a packet f detailed instructins. This new 10 digit identificatin number is required by the Affrdable Care Act (ACA) and will be utilized in Health Insurance Prtability and Accuntability Act (HIPAA) standard transactins. Attaining an HPID is required by Nvember 5, 2014, fr large self-funded health plans and by Nvember 5, 2015, fr small self-funded plans. Plans with health benefits receipts mre than $5 M (benefits fr a self-funded plan) are cnsidered large health plans. Emplyers spnsring self-funded health plans will als be required t receive certificatin frm certain vendrs f cmpliance with HIPAA s electrnic transactin rules. Self-funded plans will file certificatins by December 31, Fr fully-insured health plans, the health insurance cmpany, nt the emplyer/plan spnsr, is respnsible fr cmpliance with these new requirements. Emplyers with fully-insured plans d NOT need t btain an HPID. Insurers will apply fr the HPID fr a fully-insured health plan. EFFECTIVE DATES Nvember 5, 2014: Large self-funded plans btain the Health Plan Identifier (HPID). Plans with health benefits receipts mre than $5 M are cnsidered large health plans. Nvember 5, 2015: Small self-funded plans btain their HPID. Plans with health benefits receipts f $5 M r less are cnsidered small health plans. December 31, 2015: All self-funded plans must certify t CMS that HIPAA standard transactins are in cmpliance with HIPAA rules. Nvember 7, 2016: HPIDs required in standard HIPAA transactins fr health plans.

2 BACKGROUND INFORMATION & ACTION STEPS Emplyers Spnsring Self-Funded Health Plans Must Initiate the Fllwing Steps: APPLY fr an HPID fr the apprpriate Cntrlling Health Plan (CHP) and/r Sub Health Plans (SHPs) by Nvember 5, 2014 fr large health plans and by Nvember 5, 2015 fr small health plans. NOTE: The HPID rules intrduce new cncepts: 1) Cntrlling Health Plan and 2) Sub Health Plan Cntrlling Health Plan (CHP): Must Obtain an HPID Health plan that cntrls its wn business activities, actins r plicies; r is cntrlled by an entity that is nt a health plan; if it has a Sub Health Plan(s), exercises sufficient cntrl ver the sub health plan(s). Sub Health Plan (SHP): NOT Required t Obtain an HPID Health plan whse business activities, actins r plicies are directed by a Cntrlling Health Plan. Regulatins indicate an insurer will apply fr an HPID n behalf f a fully-insured plan because the insurer s plan is the CHP (cntrlling actins and plicies) and emplyer s fully-insured plan is the SHP. COORDINATE with vendrs prcessing HIPAA transactins n behalf f the plan t dcument and verify the vendr receives necessary HIPAA cmpliance certificatin prir t December 31, All HIPAA health plans are required t file a certificatin attesting the plan is in cmpliance with certain HIPAA transactin requirements by December 31, The certificatin prcess invlves a specific system-testing prcess defined in the regulatins and a verificatin f cmpliance by vendrs. CERTIFICATION OF COMPLIANCE WITH HIPAA TRANSACTION RULES In a separate set f requirements, all plan spnsrs f self-funded health plans are required t file a certificatin with HHS attesting the plan is in cmpliance with certain HIPAA transactin requirements by December 31, The certificatin prcess invlves a specific system-testing prcess defined in the regulatins. Additinal guidance frm HHS n the certificatin prcess is anticipated. Emplyers spnsring fully insured plans will NOT need t file a certificatin directly. PENALTY EXPOSURE HPID NOT Attained by Self-Funded Health Plans: The regulatry interpretatin indicates the same penalty applies as under HIPAA administratin simplificatin rules. A vilatin may result in a penalty f $50,000 fr willfully neglecting t attain an HPID, as well as an additinal $50,000 fr each instance in which a standard transactin ccurs, in the future, requiring an HPID. Self-Funded Health Plan Des NOT Certify Cmpliance: The penalty is $1 per cvered life per day until certificatin is cmplete with a maximum penalty f $20 per cvered life. PLANS SUBJECT TO THE HPID REQUIREMENTS HPIDs are required fr: HIPAA excepted benefits, such as stand-alne dental r stand-alne visin cverage Retiree-nly Plans 2

3 Additinal Cnsideratins: Even thugh stand-alne dental & stand-alne visin are HIPAA excepted benefits under the prtability rules fr HIPAA, these plans are nt excepted benefits under the newly issued HIPAA administratin simplificatin rule and therefre must btain an HPID. Flexible Spending Accunts (FSAs) and Health Savings Accunts (HSAs) are nt required t attain an HPID. These are individual accunts directed by the cnsumer t pay health care csts. Health Reimbursement Arrangements (HRAs) may require an HPID if they meet the definitin f health plan. HRAs that cver deductibles nly r ut-f-pcket csts d nt require HPIDs. Wrap-plans and cafeteria plans may be cmpsed f cmbinatins f health plan arrangements (i.e., self-insured, fullyinsured, FSA, HSA, HRA). The rules gverning these types f plans are the same as fr the individual plan types. Fr example, a wrap-plan that includes a fully-insured medical plan, self-insured dental plan, and HRA that cvers deductibles, wuld require the emplyer t btain an HPID nly fr the self-insured dental plan. The carrier wuld be respnsible fr btaining the HPID fr the fully-insured medical plan. The HRA nly cvers deductibles; therefre, an HPID is nt required. PLANS NOT SUBJECT TO THE HPID REQUIREMENTS Plans nt cvered by HIPAA s administrative simplificatin rules are nt required t btain an HPID. Therefre, the HPID requirements d NOT apply t the fllwing plans: Accident r disability insurance Supplemental liability insurance General liability insurance Autmbile liability insurance On-Site clinics Secndary cverage (secndary t an insurance plans) TAKEAWAYS Oswald Cmpanies hsted a detailed webinar explaining the HPID steps fr self-funded plans n September 22, Please cntact Danielle Jarvis: djarvis@swaldcmpanies.cm fr a recrding f this presentatin. See belw fr frequently asked questins in understanding these steps. Several emplyers are nting delays nce registering; therefre, large self-funded plan spnsrs (emplyers) shuld begin this prcess in advance f the deadlines t dcument cmpliance, as well as t dcument ptential system delays. Oswald Cmpanies will cntinue t mnitr updates and regulatins t implement this new prcess, and prvide guidance as additinal infrmatin is issued. Please cntact us with questins. Oswald Cmpanies Grup Health Plan Implementatin Review Andrea Esselstein, J.D. aesselstein@swaldcmpanies.cm; Luke Clark, Sr Benefits Cnsultant lclark@swaldcmpanies.cm Disclaimer: Materials are slely fr infrmatinal purpses as an educatinal resurce. Please cntact cunsel t btain advice with respect t any specific issue. 3

4 OBTAINING THE HEALTH PLAN ID NUMBER (HPID) STEP BY STEP DETAILS 2014 OBTAINING THE HEALTH PLAN ID NUMBER (HPID) NUMBER OF HPIDS REQUIRED If an emplyer has wrapped all plans int a single ERISA plan: Only ne HPID is required, as f guidance n If an emplyer cnsiders each self-funded plan as a Separate Health Plan: mmay need an HPID fr each self-funded plan Unanswered Questin: Beginning in 2016, will TPAs require separate HPIDs fr different self-funded plans even if the emplyer has a single ERISA plan? HPID HPID HPID HPID One CHP CHP CHP CHP Self-funded Medical Plan Self-funded Dental Plan Self-funded Rx Plan Self-funded Medical Plan Self-funded Dental Plan Self-funded Rx Plan HPID PROCESS HPID APPLICATION 4

5 STEP 1: CREATE CMS PORTAL ACCOUNT Creating the CMS Prtal Accunt: Click New User Registratin (right side f page) Fill Out Required Persnal Infrmatin Select Security Questins STEP 2: ACCESS HEALTH INSURANCE OVERSIGHT SYSTEM (HIOS) Lg int CMS Prtal. Select Request Access Nw. Frm System Descriptin Drp Dwn Menu: Select HIOS HIOS Applicatin Frm Rle Drp Dwn Menu: Select HIOS Issuer Fill ut the Infrmatin Frm Within 24 hurs, applicant receives an Cnfirmatin 5

6 STEP 3: ACCESS HEALTH PLAN AND OTHER ENTITY ENUMERATION SYSTEM (HPOES) Once the Cnfirmatin has been received: Lg back int CMS Prtal and click n Request Access Nw Frm System Descriptin Drp Dwn Menu: Select HIOS Applicatin Frm Rle Drp Dwn Menu: Select HIOS Issuer Enter the HIOS Authrizatin Cde prvided in the Lg ut f the CMS Server: When lgging back in, applicant will see a Yellw HIOS Tab in the upper left crner. Click n the tab, then click the fllwing link: Access HIOS 6

7 Accessing Health Plan & Other Entity Enumeratin System (HPOES): Applying fr HPOES as a Submitter: Access HIOS: Select Manage Organizatin Enter Organizatin s Federal EIN r TIN number: Select the Cmpany Type and Required Infrmatin. If the Infrmatin is Crrect, Select Submit and Return t the Hme Screen Select Rle Management and Chse Request Rle Tab Select Health Plan and Other Entity Enumeratin System (HPOES) frm the Drp Dwn Menu: Select Submitter as the Optin fr Requested Rle & Enter Infrmatin STEP 4: APPLY FOR AN HPID IN HPOES Applying fr an HPID in HPOES as the Submitter: After lgging back int HIOS, click n the new tab, Health Plan and Other Entity Enumeratin System (HPOES) Click the Create Prfile and Apply fr the HPID Tab (n the left) Select the rganizatin frm the Drp Dwn Menu Enter NAIC Number r Payer Identificatin Number (If the rganizatin des nt have either, enter Nne fr Payer Identificatin Number), then click Cntinue Fill ut the Infrmatin as the Authrizing Official Of The Cmpany (an individual able t make legally binding decisins) An will be Sent t the Authrizing Official t then lgin t Apprve the Applicatin Cnfirming the Request as the Authrizing Official: Authrizing fficial needs t lg int HIOS Click the Rle Management tab Select Health Plan and Other Entity Enumeratin System (HPOES) frm the drp dwn menu Select Authrizing Official fr Requested Rle Enter the rganizatins Federal EIN/TIN 7

8 Cnfirming the Request as the Authrizing Official (cnt.) Authrizing fficial and submitter will receive an nce yur applicatin has been apprved. Lg back int HIOS and click the Health Plan and Other Entity Enumeratin System (HIOS) Tab. Review the infrmatin given and click t apprve. Applicant will be given an HPID number shrtly after apprving the applicatin. Applicant will be ntified by when the prcess is cmplete 8

9 NEW CERTIFICATION PROCESS All Health Plans that Perfrm Standard Transactins Need t Certify T CMS Cmpliance with 3 Specific Transactins by December 31, 2015 Health Care Claim Status Health Care Electrnic Funds Transfer Remittance Advice Tw Different Methds t Certify Cmpliance with Transactin Standards CAQH CORE Certificatin HIPAA Credential Prcess Emplyers Typically D Nt Prcess the Actual Transactins HIPAA Requires Business Assciates t Cmply With HIPAA Transactin Rules when Prcessing a Transactin fr a Cvered Entity HPID RESOURCES ON CMS.gv HPID Website Identifier.html HPID User Manual Act/Dwnlads/HIOSHPOESUserManualv60.pdf HPID System Overview Presentatin Act/Dwnlads/HPOESTrainingSlides pdf CMS FAQs Oswald Cmpanies Grup Health Plan Implementatin Review Andrea Esselstein, J.D. aesselstein@swaldcmpanies.cm; Luke Clark, Sr Benefits Cnsultant lclark@swaldcmpanies.cmdisclaimer: Materials are slely fr infrmatinal purpses as an educatinal resurce. Please cntact cunsel t btain advice with respect t any specific issue. 9

10 HEALTH CARE REFORM IMPLEMENTATION FREQUENTLY ASKED QUESTIONS Health Plan Identifier Number (HPID) 2014 QUESTIONS & ANSWERS: Q: Hw will an Emplyer knw if the Plan has Health Benefit Receipts f Mre Than $5M, and therefre a Large Self-funded Plan under the HPID Regulatins? Q: D HPID Requirements Apply t Partially Self-funded Plans? A: The prcess f determining receipts is different fr fully-insured versus self-insured (and partial) plans, as fllws: 1. Fully-insured plans use the ttal amunt f premium paid by the plan fr health insurance benefits during the plan's last full fiscal year. 2. Self-insured plans use the ttal amunt paid fr health care claims by the emplyer, plan spnsr r benefit fund (n behalf f the plan) during the plan's last full fiscal year. 3. Partially fully-insured and self-insured plans use cmbined measures t determine the ttal annual receipts. A: If an emplyer has a partially self-funded plan, it will be necessary t crdinate with the carrier t determine whether r nt the carrier is btaining an HPID (number) n the plan s behalf. If the carrier cnsiders the plan t be self-funded, the emplyer/plan spnsr must btain the HPID. Q: Hw Shuld Multi- Emplyer Plans Address the HPID Requirements? A: N frmal guidance has been released defining hw t address multiple plans ffered by a single emplyer; hwever, a reasnable apprach is t align the plan size determinatin with hw the plans are identified in the emplyer s 5500 filing. If an emplyer wraps all plans int a single wrap plan and files a 5500 under a single plan number, the emplyer shuld cnsider the claims in all health-related benefits (e.g. medical, dental, visin, etc.) in determining the $5 millin threshld. Q: Are Separate HPID Numbers Required fr Standalne Dental and/r Stand-alne Visin Plans? Q: Is it Permissible fr Benefits Manager t als be the Authrizer r des it Need t be an Officer? A: Based n guidance as f Octber 1, 2014, if an emplyer wrapped all health plans int a single ERISA plan, nly ne HPID is required. If an emplyer cnsiders each self-funded plan as a separate health plan, an HPID may be necessary fr each self-funded plan. Further guidance awaits this unanswered questin: Beginning in 2016, will TPAs require separate HPIDs fr different self-funded plans even if the emplyer has a single ERISA plan? A: The guidance des nt specify the required credentials r emplyee level t qualify as Authrizing Official. Hwever, an Authrizing Official must be an emplyee with the authrity t legally bind the entity. Accrding t the CMS HPID instructins manual, the Authrizing Official is described as: an individual that has the authrity t legally bind the entity and hlds ultimate respnsibility, fr example the chief executive fficer (CEO), the chief cmpliance fficer, and the chief financial fficer (CFO). Additinally, the Authrizing Official, apprves the applicatin. The Authrizing Official must als have his r her wn separate CMS prtal access. This means he r she will need t cmplete the security related questins including birthdate and address (SSN is nt required) befre the cmpany is able t cmplete the HPID prcess. 10

11 Q: Are Emplyers (Submitters f Infrmatin t the CMS Website) Required t Prvide Scial Security Numbers, Addresses and Persnal Infrmatin? What Security Requirements Shuld Emplyers Anticipate in the New Prtal? Q: If an Emplyer has Becme Selffunded After Being Fully-insured in the Previus Plan Year (and has $5M in Receipts), when is the HPID Required? A: Obtaining a CMS prtal accunt is necessary. As part f the security prcess the submitter is required t prvide an address and birthdate. A scial security number may be prvided, but it is nt required. Imprtantly, an emplyer is nt required t give this infrmatin t btain the HPID. Emplyers cannt access the next steps until a CMS prtal accunt is btained first. Security Requirements include: Username Passwrd Three (self chsen) security questins and prvided answers A: There is n specific guidance regarding HPIDs, but HIPAA rules state large plan status fr fully insured plans is based n ttal premiums fr the prir plan year. Fr self-funded plans, this is based n claims paid. If the prir plan year had $5 millin in claims, it is reasnable t assume the ttal premium was als $5 millin and therefre a large plan (and need an HPID must be btained by Nv. 5, 2014). Oswald Cmpanies Grup Health Plan Implementatin Review Andrea Esselstein, J.D. aesselstein@swaldcmpanies.cm; Luke Clark, Sr. Benefits Cnsultant lclark@swaldcmpanies.cm Jhn Fasla, VP, Directr Grup Benefits jfasla@swaldcmpanies.cm Disclaimer: Materials are slely fr infrmatinal purpses as an educatinal resurce. Please cntact cunsel t btain advice with respect t any specific issue 11