Health Plans Under HIPAA
Health Plans are important to Americans. HIPAA applies to health plans, health care providers and health care clearinghouses.
What does HIPAA Consider a Health Plan?
Today, I want to focus on its applicablity to health plans. 45 CHR 160.102(a)(1). Health plans are probably familiar to you. These are most often known as health insurance companies. More specifically, a health plan means an individual or group plan that provides or pays the cost of medical care.
I’ll provide a quick list of further definitional aspects of what consitutues a health plan. A health plan can have one or several aspects of the following:
(i) A group health plan;
(ii) A health insurance issuer;
(iii) An HMO (Health Maintence Organization);
(iv) Part A or Part B of the Medicare program;
(v) The Medicaid program;
(vi) An issuer of a Medicare supplemental policy;
(vii) An issuer of a long-term care policy, excluding a nursing home fixed-indemnity policy;
(viii) An employee welfare benefit plan or any other arrangement that is established or maintained for the purpose of offering or providing health benefits to the employees of two or more employers;
(ix) The health care program for active military personnel under title 10 of the United States Code;
(x) The veterans health care program under 38 U.S.C. chapter 17;
(xi) The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS);
(xii) The Indian Health Service program under the Indian Health Care Improvement Act;
(xiii) The Federal Employees Health Benefits Program;
(xiv) An approved State child health plan under title XXI; providing benefits for child health assistance;
(xv) The Medicare+Choice program under Part C of title XVIII;
(xvi) A high risk pool that is a mechanism established under State law to provide health insurance coverage or comparable coverage to eligible individuals;
(xvii) Any other individual or group plan, or combination of individual or group plans, that provides or pays for the cost of medical care.
What’s not considered a health plan under HIPAA?
Any discussion of what a health plan includes should also include a list of what’s excluded from the definition of a health plan. These exclusions include:
(ii) A government-funded program (other than one listed in paragraph (1)(i)–(xvi) of this definition):
(A) Whose principal purpose is other than providing, or paying the cost of, health care; or
(B) Whose principal activity is:
(1) The direct provision of health care to persons; or
(2) The making of grants to fund the direct provision of health care to persons.
Under HIPAA, there is a rather specific laundry list of what is and isn’t a health plan.
It’s intuitve to think you already know what a health plan looks like for general purposes, but I hope that it was helpful to receive more details regarding how HIPAA defines a health plan.
If your organization would like further training, please contact me at