Section 4.5: Conducting Underwriting Activities

Section 4.5: Conducting Underwriting Activities

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Release Date: 
September 23, 2013
Responsible Offices: 
Employee Benefits

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Under HIPAA, a Group Health Plan may condition eligibility for enrollment on the Member’s Authorization to allow PHI to be obtained for the purpose of risk rating or underwriting an Individual enrollment. In some circumstances, System may, if otherwise permitted by law require evidence of insurability as a condition of a Member’s enrollment in a Group Health Plan. In such cases, enrollment will be conditional upon the Individual ’s Authorization for System to receive PHI for underwriting purposes.

4.5(1) Conditioning Plan Enrollment on the Individual’s Authorization

A Member’s ability to be enrolled in a Group Health Plan may, if otherwise permitted by law, be conditioned on the Member’s provision of a valid Authorization for OEB to obtain PHI for the purpose of underwriting, premium rating, or other activities relating to the creation, renewal, or replacement of a contract of health insurance or health benefits (collectively, “underwriting activities”) based on its current Self-funded Group Health Plan’s requirements relating to evidence of insurability. Such Authorization shall not permit the Use or Disclosure of Psychotherapy Notes.

4.5(2) Request for PHI for Underwriting Activities

Unless and until EGI receives an Individual’s Authorization, EGI shall not request the Individual’s PHI from other entities in order to conduct underwriting activities.

4.5(3) Use and Disclosure of PHI Received for Underwriting Activities

Unless and until a Member is enrolled in a Group Health Plan, EGI shall not Use and Disclose PHI received for underwriting activities except for such underwriting activities or as otherwise required by law. Upon the Member’s enrollment, EGI may Use and Disclose such PHI as permitted by this Manual.

4.5(4) Use and Disclosure of Genetic Information for Underwriting Activities

System shall not use or disclose protected health information that is Genetic Information for underwriting purposes. Underwriting purposes does not include determinations of medical appropriateness where an Individual seeks a benefit under the plan, coverage, or policy.

REFERENCES/CITATIONS

45 C.F.R. §§ 164.502(a)(5)(1), 164.508(b)(4)(ii), 164.514(g)

65 Fed. Reg. at 82,514, 46 (Dec. 28, 2000)

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