Standards for Privacy of Individually Identifiable Health Information. Final Privacy Rule Preamble.. Prohibition on Conditioning Treatment, Payment, Eligibility, or Enrollment

12/28/2000

Comment: Many commenters supported the NPRM's prohibition of covered entities from conditioning treatment or payment on the individual's authorization of uses and disclosures. Some commenters requested clarification that employment can be conditioned on an authorization. Some commenters recommended that we eliminate the requirement for covered entities to state on the authorization form that the authorization is not a condition of treatment or payment. Some commenters suggested that we prohibit the provision of anything of value, including employment, from being conditioned on receipt of an authorization.

In addition, many commenters argued that patients should not be coerced into signing authorizations for a wide variety of purposes as a condition of obtaining insurance coverage. Some health plans, however, requested clarification that health plan enrollment and eligibility can be conditioned on an authorization.

Response: We proposed to prohibit covered entities from conditioning treatment, payment, or enrollment in a health plan on an authorization for the use or disclosure of psychotherapy notes (see proposed § 164.508(a)(3)(iii)). We proposed to prohibit covered entities from conditioning treatment or payment on authorization for the use or disclosure of any other protected health information (see proposed § 164.508(a)(2)(iii)).

We resolve this inconsistency by clarifying in § 164.508(b)(4) that, with certain exceptions, a covered entity may not condition the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits on an authorization for the use or disclosure of any protected health information, including psychotherapy notes. We intend to minimize the potential for covered entities to coerce individuals into signing authorizations for the use or disclosure of protected health information when such information is not essential to carrying out the relationship between the individual and the covered entity.

Pursuant to that goal, we have created limited exceptions to the prohibition. First, a covered health care provider may condition research-related treatment of an individual on obtaining the individual's authorization to use or disclose protected health information created for the research. Second, except with respect to psychotherapy notes, a health plan may condition the individual's enrollment or eligibility in the health plan on obtaining an authorization for the use or disclosure of protected health information for making enrollment or eligibility determinations relating to the individual or for its underwriting or risk rating determinations. Third, a health plan may condition payment of a claim for specified benefits on obtaining an authorization under § 164.508(e) for disclosure to the plan of protected health information necessary to determine payment of the claim. Fourth, a covered entity may condition the provision of health care that is solely for the purpose of creating protected health information for disclosure to a third party (such as fitness-for-duty exams and physicals necessary to obtain life insurance coverage) on obtaining an authorization for the disclosure of the protected health information. We recognize that covered entities need protected health information in order to carry out these functions and provide services to the individual; therefore, we allow authorization for the disclosure of the protected health information to be a condition of obtaining the services.

We believe that we have prohibited covered entities from conditioning the services they provide to individuals on obtaining an authorization for uses and disclosures that are not essential to those services. Due to our limited authority, however, we cannot entirely prevent individuals from being coerced into signing these forms. We do not, for example, have the authority to prohibit an employer from requiring its employees to sign an authorization as a condition of employment. Similarly, a program such as the Job Corps may make such an authorization a condition of enrollment in the Job Corps program. While the Job Corps may include a health care component, the non-covered component of the Job Corps may require as a condition of enrollment that the individual authorize the health care component to disclose protected health information to the non-covered component. See § 164.504(b). However, we note that other nondiscrimination laws may limit the ability to condition these authorizations as well.

Comment: A Medicaid fraud control association stated that many states require or permit state Medicaid agencies to obtain an authorization for the use and disclosure of protected health information for payment purposes as a condition of enrolling an individual as a Medicaid recipient. The commenter, therefore, urged an exception to the prohibition on conditioning enrollment on obtaining an authorization.

Response: As explained above, under § 164.506(a)(4), health plans and other covered entities may seek the individual's consent for the covered entity's use and disclosure of protected health information to carry out treatment, payment, or health care operations. If the consent is sought in conjunction with enrollment, the health plan may condition enrollment in the plan on obtaining the individual's consent.

Under § 164.506(a)(5), we specify that a consent obtained by one covered entity is not effective to permit another covered entity to use or disclose protected health information for payment purposes. If state law requires a Medicaid agency to obtain the individual's authorization for providers to disclose protected health information to the Medicaid agency for payment purposes, the agency may do so under § 164.508(e). This authorization must not be a condition of enrollment or eligibility, but may be a condition of payment of a claim for specified benefits if the disclosure is necessary to determine payment of the claim.