Health Plan Identifier and Health Plans

Health Plan Identifier (HPID) Final Regulations

Read eHealth’s blog post by Matthew Albright, Director, Administrative Simplification Group, HPID: What’s it all about?

The following is communication from CMS eHealth.

What Is a health plan?
Both the Health Plan Identifier (HPID) final regulations and the recently published Certification of Compliance proposed regulations have requirements that apply to controlling health plans (CHPs). Before you can determine whether you’re a controlling health plan, however, you must answer the underlying question, “what is a health plan?”

This question is not as simple as it sounds. A health care “payer,” the term most often used in the health care industry vernacular and even within X12 standard transactions, does not always meet the definition of “health plan.” Similarly, there are HIPAA-covered “health plans” that rely on entities (which are not health plans) to manage the administration of billing and payment of health care (e.g., Administrative Services Organizations or Third-Party Administrators).

Health Plans by Definition
By definition (45 U.S.C. §160.103), a health plan is “an individual or group plan that provides, or pays the cost of, medical care.”

The term medical care (42 U.S.C. 300gg-91(a)(2)) includes insurance covering and amounts paid for:

  • Diagnosis, cure, mitigation, treatment, or prevention of disease
  • The purpose of affecting any structure or function of the body
  • Transportation for and to medical care referred to in the bullets above

A health plan includes, but is not limited to:

  • A group health plan
  • A health insurance issuer
  • A health maintenance organization (HMO)
  • An employee welfare benefit plan or any other arrangement with the purpose of providing health benefits to the employees of two or more employers
  • Any other individual or group plan (or combination of individual or group plans) that provides or pays for the cost of medical care
  • Government programs (e.g., Medicare, Medicaid, Veterans Affairs, Indian Health Service, Federal Employee Health Benefits, etc.)

CMS has posted a set of flow charts on its website to help an organization determine whether it is a covered entity. Each chart represents a different type of entity, including health plans, health care clearinghouses, or health care providers.

Health Plans and HPIDs
Now that you know whether your organization is a health plan or not, it’s on to the enumeration process, which is used to register for an HPID. In an upcoming blog, we will present a pre-enumeration check list to help you prepare for accessing the Health Plan and Other Entity Enumeration System (HPOES), the web-based system used to request an HPID or Other Entity Identifier (OEID).

Want more information about enumeration?
Visit the HPID website for the latest news and resources.