OCR FAQs  

 

Dated Oct. 2, 2002
Source: http://www.hipaadvisory.com/action/faqs/faqs1001.doc

· Is a physician required to have business associate contracts with technicians such as plumbers, electricians or photocopy machine repairmen who provide repair services in a physician's office?

Response: No, plumbers, electricians and photocopy repair technicians do not require access to protected health information to perform their services for a physician's office, so they do not meet the definition of a business associate. Under the Privacy Rule, "business associates" are contractors or other non-workforce members hired to do the work of, or for, a covered entity that involves the use or disclosure of protected health information. See 45 C.F.R § 160.501.


· Are janitorial services business associates?

Response: Generally, janitorial services that clean the facilities of a covered entity (i.e., a health care provider, health plan or health care clearinghouse) are not business associates because the work they perform for covered entities does not involve the use or disclosure of protected health information, and any disclosure of protected health information to janitorial personnel that occurs in the performance of their duties (such as may occur while emptying trash cans) is limited in nature, occurs as a by-product of their janitorial duties, and could not be reasonably prevented. Such disclosures are incidental and permitted by the Privacy Rule. See 45 C.F.R. § 164.502(a)(1).

If a service is hired to do work for a covered entity where disclosure of protected health information is not limited in nature (such as routine handling of records or shredding of documents containing protected health information), it likely would be a business associate. However, when such work is performed under the direct control of the covered entity (e.g., on the covered entity's premises), the Privacy Rule permits the covered entity to treat the service as part of its workforce, and the covered entity need not enter into a business associate contract with the service. See 65 Fed. Reg. 82462, 82480 (December 28, 2000).

· Are the following entities considered "business associates" under the Privacy Rule: US Postal Service, United Parcel Service, delivery truck line employees and/or their management?

Response: No, the Privacy Rule does not require a covered entity to enter into business associate contracts with organizations, such as the US Postal Service, certain private couriers and their electronic equivalents that act merely as conduits for protected health information. A conduit transports information but does not access it other than on a random or infrequent basis as necessary for the performance of the transportation service or as required by law. Since no disclosure is intended by the covered entity and the probability of exposure of any particular protected health information to a conduit is very small, a conduit is not a business associate of the covered entity. See 65 Fed. Reg. 82462, 82476 (December 28, 2000).

· Are State, county or local health departments required to comply with the Privacy Rule?

Response: Yes, if a State, county or local health department performs functions that make it a covered entity, or otherwise meets the definition of a covered entity. For example, a state Medicaid program is a covered entity (i.e., a health plan) as defined in the Privacy Rule. Some health departments operate health care clinics and thus are health care providers. If these health care providers transmit health information electronically in connection with a transaction covered in the HIPAA Transactions Rule, they are covered entities. For more information, see the definitions of covered entity, health care provider, health plan and health care clearinghouse in 45 C.F.R.§160.103. See also, the "Covered Entity Decision Tools" posted at http://www.cms.gov/hipaa/hipaa2/support/tools/decisionsupport/default.asp. These tools address the question of whether a person, business or agency is a covered health care provider, health care clearinghouse or health plan.

If the health department performs some covered functions (i.e., those activities that make it a provider that conducts certain transactions electronically, a health plan or a health care clearinghouse) and other non-covered functions, it may designate those components (or parts thereof) that perform covered functions as the health care component(s) of the organization and thereby become a type of covered entity known as a "hybrid entity." Most of the requirements of the Privacy Rule apply only to the hybrid entity's health care component(s). If a health department elects to be a hybrid entity, there are restrictions on how its health care component(s) may disclose protected health information to other components of the health department. See 45 C.F.R. § 164.504 (a) - (c) for more information about hybrid entities.

· Are the following types of insurance covered under HIPAA: long/short term disability; workers compensation; automobile liability that includes coverage for medical payments?

Response: No, the listed types of policies are not health plans. The HIPAA administrative simplification regulations specifically exclude from the definition of a "health plan" any policy, plan, or program to the extent that it provides, or pays for the cost of, excepted benefits, which are listed in section 2791(c)(1) of the Public Health Service Act, 42 U.S.C. 300gg-91(c)(1). See 45 C.F.R. § 160.103. As described in the statute, excepted benefits are one or more (or any combination thereof) of the following policies, plans or programs:

o Coverage only for accident, or disability income insurance, or any combination thereof.
o Coverage issued as a supplement to liability insurance.
o Liability insurance, including general liability insurance and automobile liability insurance.
o Workers' compensation or similar insurance.
o Automobile medical payment insurance.
o Credit-only insurance.
o Coverage for on-site medical clinics
o Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

· Is an entity that is acting as a third party administrator to a group health plan a covered entity?

Response: No, providing services to or acting on behalf of a health plan does not transform a third party administrator (TPA) into a covered entity. Generally, a TPA of a group health plan would be acting as a business associate of the group health plan. Of course, the TPA may meet the definition of a covered entity based on its other activities (such as by providing group health insurance). See 45 C.F.R. § 160.103.

· HIPAA allows "small health plans," defined as health plans having annual receipts of $5 million or less, an additional year (in the case of the Privacy Rule, until April 14, 2004) to come into compliance. How should a health plan determine what receipts to use to decide whether it qualifies as a "small health plan?"

Response: Health plans that file certain federal tax returns and report receipts on those returns should use the guidance provided by the Small Business Administration at 13 C.F.R. § 121.104 to calculate annual receipts. Health plans that do not report receipts to the IRS - for example, ERISA group health plans that are exempt from filing income tax returns - should use proxy measures to determine their annual receipts. Further information about the relevant provisions of 13 C.F.R. § 121.104 and these proxy measures, and additional information related to "small health plans," may be found at
http://cms.hhs.gov/ hipaa/hipaa2/default.asp