The Health Insurance Portability and Accountability Act of 1996 (HIPAA) contains provisions intended to guarantee that employees and their dependents who leave an employer's group health plan have ready access to a subsequent employer's health plan, regardless of their health or claims experience.

HIPAA regulations require that employers keep records of the health care coverage of plan participants and that documentation certifying prior coverage be issued for a participant or their dependents after the loss of coverage from an employer group health plan.

Former plan participants and their dependents can request HIPAA certification any time within 24 months after termination of coverage.

Oracle HRMS provides the ability to generate HIPAA certifications through the use of two HIPAA communication triggers that are seeded with the product, one for participant loss of coverage and one for dependent loss of coverage. You can generate and print HIPAA letters for participants and dependents directly from the application.

Setting Up HIPAA Certification

Follow this process to set up the application so that you can generate HIPAA certificates for qualifying individuals. As a prerequisite, you should already have defined the compensation objects that comprise your benefits package.

Define Plans Subject to HIPAA Regulations

The application triggers a HIPAA certificate when a loss of coverage occurs for a participant or a dependent covered by a plan subject to HIPAA and the person no longer has any electable choices for any other plans subject to HIPAA in the plan type.

You define a plan as subject to HIPAA by linking the HIPAA regulation to the plan.

   To define a plan subject to HIPAA regulations:

1. Define a plan subject to HIPAA regulations in the Plans window.

2. Choose the Details button.

3. Choose the Regulations tabbed region.

4. Select the HIPAA regulation type.

Define a HIPAA Communication Type

You define a HIPAA communication type so that a HIPAA certification is triggered for all qualified participants and dependents when coverage in a plan is terminated and the person no longer has any electable choices for any other plans subject to HIPAA in the plan type.

See: Defining Communication Types

   To define a HIPAA communication type:

1. Query one of the seeded HIPAA communication types in the Communication Types window. Choose either:

   • HIPAA Letter

   • HIPAA Dependent Letter

2. Choose the Triggers button.

3. Select a HIPAA communication trigger in the Communication Type Triggers window. Choose either:

   • HIPAA Participant Deenrollment

   • HIPAA Dependent Loss of Coverage

   Note: When a participant loses coverage, one HIPAA letter is generated if the participant and his or her dependents all reside together. Dependents who do not reside with the participant receive a separate letter.

4. Close the Communication Type Triggers window.

5. Choose the Usages button.

6. Select the plan types to which this HIPAA communication type applies in the Communication Type Usages window.

Set up the Administrator Contact

You enter an administrator's contact information to provide the name and return address on the HIPAA certificate. You can set up contacts by plan, or establish one contact for all plans in a program. Contacts you set up at the program level override contacts you enter for any plans in the program.

See: Associating an Organization with a Benefits Program

See: Associating Options with a Plan

   To set up an administrator contact:

1. To enter an administrator for a program, open the Programs window and select the Organizations tab.

2. Select the administrator's Organization.

   You must first enter your organizations using the Organization window.

3. Enter the administrator's name in the Organization Roles field.

4. In the Organization Role Types field, select Administrator.

5. Save your work.

6. To enter an administrator for a plan, open the Plans window. Choose the Details button and select the Organizations tab.

7. Complete the fields as you would for a program, following steps 2-5.

   Note: The address you define for the organization in the Organization window also appears in the letters.

Generate HIPAA Certificates

Run the HIPAA Letter report to generate HIPAA certificates for participants. For dependents who reside with the participant, the report generates a single letter. Dependents who do not live with the participant each receive a letter.

Use the HIPAA Dependent Letter report to generate HIPAA certificates for dependents only. For example, dependents who age out of a plan receive a HIPAA certificate, even though the participant may still be enrolled in the plan.

The participant or dependent must have the communication type detected in the Person Communication window for either report to generate a letter. The reports update the Person Communication window with the Sent Date once the process is complete.

The reports extract participant and plan data from Oracle HRMS and merge the data into the body of the seeded HIPAA letters. The extracted information includes:

• Administrator's name and mailing address

• Participant's name, address, and Social Security Number

• Date the certificate was issued (equal to the process run date)

• Business group

• Plan name

• Waiting period start and end date (if the person's enrollment was less than 12 months)

• Coverage start and end date

• Covered dependents under each plan

You run reports from the Submit Requests window.

   To generate a HIPAA certificate for a participant:

1. Select the HIPAA Letter report in the Name field.

2. Enter the Parameters field to open the Parameters window.

3. Select an individual in the Person Name field to generate a certificate for a single person.

4. To generate a HIPAA certificate for multiple persons, select one or more of the following criteria:

   • Organization

   • Benefit Group

   • Location

   • Program

   The report generates a certificate for each participant and dependent who has a detected HIPAA Participant Deenrollment communication type.

5. Choose the OK button.

6. Choose the Options button to select a printer if you want to send the certificate directly to a printer.

7. Complete the batch process request and choose Submit.

   To run the HIPAA Dependent Letter report:

1. Select the HIPAA Dependent Letter report in the Name field.

2. Enter the Parameters field to open the Parameters window.

3. Select an individual in the Person Name field to generate a certificate for a single person.

4. To generate a HIPAA certificate for multiple dependents, select one or more of the following criteria:

   • Benefit Group

   • Program

   The report generates a certificate for each dependent who has a detected HIPAA Dependent Loss of Coverage communication type.

5. Choose the OK button.

6. Choose the Options button to select a printer if you want to send the certificate directly to a printer.

7. Complete the batch process request and choose Submit.

Define a System Extract for HIPAA

If you do not want to use the seeded HIPAA letters, you can define a system extract profile to extract the data you want to include in a HIPAA certificate that you maintain.

See: Defining an Extract Criteria Profile

   To define a system extract for HIPAA:

1. Define an extract criteria profile using the Criteria Definition window.

2. Choose the Communications tab.

3. Select a Criteria Type of Person Communication - Type.

   • Select a HIPAA Communication Type that you have defined.

4. Select a Criteria Type of Person Communication Provided - To Be Sent Date and check the Exclude field.

   • Select Beginning of Time as the From value and Today as the To value so that communications which have already been sent are not re-sent.

5. Select a Criteria Type of Person Communication Provided - Sent Date to exclude

   • Select Beginning of Time as the From value and End of Time as the To value.

6. Choose the Benefits tab.

7. Select a Criteria Type of Enrollment Coverage During Period.

   • Select 18 Months Ago as the From value and Today as the To value.

8. Select a Criteria Type of Enrollment Status and check the Exclude field.

   • Select the Values of Backed Out and Voided to prevent these types of canceled enrollment records from appearing in the extract.

9. Select a Criteria Type of Enrollment Data Links.

   • Select a value of Extract Enrollments Linked to Communications via Usages so that the enrollment records in this HIPAA extract are restricted to the compensation objects associated with this HIPAA communication type.

   See: Defining When a Communication is Used

10. Select a Criteria Type of Benefits DateTrack Override Date.

    • Enter the effective start date of the HIPAA communication extract.

11. Select other extract criteria as necessary to limit the data to include in the HIPAA Certification letter.

12. Define the extract layout using the Layout Definition window.

13. Complete the extract definition using the Define Extract window.

    • Choose the Options tab and check the Special Handling for Dependents (ANSI 834, HIPAA) field.

    Note: If you check this field, you should consider selecting the data element of Person Participation Type (ANSI) when defining the layout for this extract to distinguish participant and dependent enrollment records in the extract results.

14. Run the Extract Process from the Concurrent Manager for the HIPAA extract you have defined.

    The Extract Process creates a flat file with the results of the extract. You can use these results in a mail merge program to create individual HIPAA Certification letters.