Pursuant to 164.530(k) a group health plan is not subject to the Privacy standards if the group health plan provides health benefits solely through an insurance contract with a health insurance issuer or an HMO and the health insurane issuer or HMO with respect to the group health plan only discloses eligibility, enrollment and disenrollment information and summary information (claims information that doesn't identify a member) to an employer group.
My two questions are:
If a group health plan of an employer fall under the above definition (fully-insured), however decides to become self-funded, would our organization then be allowed to provide the claims experience by member to the employer in order for them to send to the stop-loss carrier?
And, what if the employer is in the process to determine if they want to become self-funded, would our organization be allowed to provide the employer claims experience by member to the employer in order for them to send to the stop-loss carrier?
Thank you in advance for your comments.
Traci Jensen, CHC
Health Alliance Medical Plans, Inc.
Compliance Programs Manager
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