Am I a HIPAA Covered Entity?

The Administrative Simplification standards adopted by HHS under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) apply to any entity that is:

  • a health care provider that conducts certain transactions in electronic form (called here a “covered health care provider”),
  • a health care clearinghouse, or
  • a health plan

An organization or individual that is one or more of these types of entities is referred to as a “covered entity” in the Administrative Simplification regulations, and must comply with the requirements of those regulations.

Source: www.cms.gov

Answer the questions below to determine if you are a Covered Entity:

Am I a Health Care Provider?

Does the person, business, or agency furnish, bill or receive payment for, health care in the normal course of business?

No
You are NOT a Covered Health Care Provider
Yes
Does the person, business or agency transmit (send) any covered transactions electronically?
You ARE a Covered Health Care Provider
You are NOT a Covered Health Care Provider

 

Am I a Health Care Clearinghouse?

Does the business or agency process, or facilitate the processing of, health information from nonstandard format or content into standard format or content or from standard format or content into nonstandard format or content?

No
You are NOT a Health Care Clearinghouse
Yes
Does the business or agency perform this function for another legal entity?
You ARE a Health Care Clearinghouse
You are NOT a Health Care Clearinghouse

 

Is a Private Benefit Plan a Health Plan?

Is the plan an individual or group plan, or combination thereof, that provides, or pays for the cost of, medical care?

No
The Plan is NOT a Health Plan
Yes
Is the plan a group health plan?
Continue with the questions below…

Can you answer “Yes” to any of the following:

Is the plan a health insurance issuer?
The Plan IS a Health Plan
Is the plan an issuer of a Medicare supplemental policy?
The Plan IS a Health Plan
Is the plan an HMO?
The Plan IS a Health Plan
Is the plan a multi-employer welfare benefit plan?
The Plan IS a Health Plan
None of the above
Continue with the questions below…

Is the plan an issuer of long-term care policies?

Yes
Does the plan provide only nursing home fixed-indemnity policies?
The Plan is NOT a Health Plan
The Plan IS a Health Plan
No
Does the plan provide only excepted benefits?
The Plan is NOT a Health Plan
The Plan IS a Health Plan

 

If you got this far, you probably aren’t a Covered Entity…

But You May Still be a Business Associate…

A “business associate” is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity.

Check the HHS Website for more details and examples.