Healthcare Reform for Self-Funded Employers

ADMINISTRATIVE SIMPLIFICATION

Administrative Simplification

Important Notice: On Oct. 4, 2017, the U.S. Department of Health and Human Services (HHS) published a withdrawal notice in the Federal Register for the proposed rule titled “Administrative Simplification: Certificate of Compliance for Health Plans.” Please note that health benefit plans must still comply with HIPAA-mandated standards and operating rules for electronic transactions. Also, HHS retains the authority to review plans for compliance. But withdrawal of the proposed rule means that plans will not have to certify their compliance as outlined in the proposed rule.

Previously, on Oct. 31, 2014, HHS had announced a delay in enforcing Health Plan Identifier requirements until further notice.

The U.S. Department of Health and Human Services (HHS) published a proposed rule requiring all health plans to submit information and documentation demonstrating compliance with standards and operating rules for certain electronic transactions.

Key organizations:

CAQH: Council for Affordable Quality Health Care
CORE: CAQH’s Committee on Operating Rules on Information Exchange

Proposed rule requirements:

Controlling health plans*, including self-funded plans, have to get either a CAQH/CORE “seal” or a “HIPAA” credential showing that they meet HIPAA electronic standard transactions; and
Controlling health plans, including self-funded plans, have to send proof that they received this certification.

Proposed certification deadlines
According to the proposed rule, a controlling health plan that obtains an HPID**:

before Jan. 1, 2015, must meet the submission requirements for the first certification of compliance on or before Dec. 31, 2015.
on or after Jan. 1, 2015, and on or before Dec. 31, 2016, must meet the submission requirements for the first certification of compliance within 365 calendar days of obtaining an HPID.
after Dec. 31, 2016, is not required to meet the requirements proposed in this rule for the first certification of compliance.

*Controlling health plans control their own business activities, actions or policies, or are controlled by an entity that is not a health plan.
**On Oct. 31, 2014, HHS announced a delay in enforcing HPID requirements until further notice.