Section 160.203(a) - Criteria for Exception Determinations
Comment: Numerous comments criticized the proposed criteria for their substance or lack thereof. A number of commenters argued that the effectiveness language that was added to the third statutory criterion made the exception so massive that it would swallow the rule. These comments generally expressed concern that laws that were less protective of privacy would be granted exceptions under this language. Other commenters criticized the criteria generally as creating a large loophole that would let state laws that do not protect privacy trump the federal privacy standards.
Response: We agree with these comments. The scope of the statutory criteria is ambiguous, but they could be read so broadly as to largely swallow the federal protections. We do not think that this was Congress's intent. Accordingly, we have added language to most of the statutory criteria clarifying their scope. With respect to the criteria at 1178(a)(2)(A)(i), this clarifying language generally ties the criteria more specifically to the concern with protecting and making more efficient the health care delivery and payment system that underlies the Administrative Simplification provisions of HIPAA, but, with respect to the catch-all provision at section 1178(a)(2)(A)(i)(IV), also requires that privacy interests be balanced with such concerns, to the extent relevant. We require that exceptions for rules to ensure appropriate state regulation of insurance and health plans be stated in a statute or regulation, so that such exceptions will be clearly tied to statements of priorities made by publicly accountable bodies (e.g., through the public comment process for regulations, and by elected officials through statutes). With respect to the criterion at section 1178(a)(2)(A)(ii), we have further delineated what "addresses controlled substances" means. The language provided, which builds on concepts at 21 U.S.C. 821 and the Medicare regulations at 42 CFR 1001.2, delineates the area within which the government traditionally regulates controlled substances, both civilly and criminally; it is our view that HIPAA was not intended to displace such regulation.
Comment: Several commenters urged that the request for determination by the Secretary under proposed § 160.204(a) be limited to cases where an exception is absolutely necessary, and that in making such a determination, the Secretary should be required to make a determination that the benefits of granting an exception outweigh the potential harm and risk of disclosure in violation of the regulation.
Response: We have not further defined the statutory term "necessary", as requested. We believe that the determination of what is "necessary" will be fact-specific and context dependent, and should not be further circumscribed absent such specifics. The state will need to make its case that the state law in question is sufficiently "necessary" to accomplish the particular statutory ground for exception that it should trump the contrary federal standard, requirement, or implementation specification.
Comment: One commenter noted that a state should be required to explain whether it has taken any action to correct any less stringent state law for which an exception has been requested. This commenter recommended that a section be added to proposed § 160.204(a) stating that "a state must specify what, if any, action has been taken to amend the state law to comply with the federal regulations." Another comment, received in the Transactions rulemaking, took the position that exception determinations should be granted only if the state standards in question exceeded the national standards.
Response: The first and last comments appear to confuse the "more stringent" criterion that applies under section 1178(a)(2)(B) of the Act with the criteria that apply to exceptions under section 1178(a)(2)(A). We are also not adopting the language suggested by the first comment, because we do not agree that states should necessarily have to try to amend their state laws as a precondition to requesting exceptions under section 1178(a)(2)(A). Rather, the question should be whether the state has made a convincing case that the state law in question is sufficiently necessary for one of the statutory purposes that it should trump the contrary federal policy.
Comment: One commenter stated that exceptions for state laws that are contrary to the federal standards should not be preempted where the state and federal standards are found to be equal.
Response: This suggestion has not been adopted, as it is not consistent with the statute. With respect to the administrative simplification standards in general, it is clear that the intent of Congress was to preempt contrary state laws except in the limited areas specified as exceptions or carve-outs. See, section 1178. This statutory approach is consistent with the underlying goal of simplifying health care transactions through the adoption of uniform national standards. Even with respect to state laws relating to the privacy of medical information, the statute shields such state laws from preemption by the federal standards only if they are "more" stringent than the related federal standard or implementation specification.
Comment: One commenter noted that determinations would apply only to transactions that are wholly intrastate. Thus, any element of a health care transaction that would implicate more than one state's law would automatically preclude the Secretary's evaluation as to whether the laws were more or less stringent than the federal requirement. Other commenters expressed confusion about this proposed requirement, noting that providers and plans operate now in a multi-state environment.
Response: We agree with the commenters and have dropped the proposed requirement. As noted by the commenters, health care entities now typically operate in a multi-state environment, so already make the choice of law judgements that are necessary in multi-state transactions. It is the result of that calculus that will have to be weighed against the federal standards, requirements, and implementation specifications in the preemption analysis.
Comment: One comment received in the Transactions rulemaking suggested that the Department should allow exceptions to the standard transactions to accommodate abbreviated transactions between state agencies, such as claims between a public health department and the state Medicaid agency. Another comment requested an exception for Home and Community Based Waiver Services from the transactions standards.
Response: The concerns raised by these comments would seem to be more properly addressed through the process established for maintaining and modifying the transactions standards. If the concerns underlying these comments cannot be addressed in this manner, however, there is nothing in the rules below to preclude states from requesting exceptions in such cases. They will then have to make the case that one or more grounds for exception applies.
Section 160.204(a) - Process for Exception Determinations - Comments and Responses
Comment: Several comments received in the Transactions rulemaking stated that the process for applying for and granting exception determinations (referred to as "waivers" by some) needed to be spelled out in the final rule.
Response: We agree with these comments. As noted above, since no process was proposed in the Transactions rulemaking, a process for making exception determinations was not adopted in those final rules. Subpart B below adopts a process for making exception determinations, which responds to these comments.
Comment: Comments stated that the exception process would be burdensome, unwieldy, and time-consuming for state agencies as well as the Department. One comment took the position that states should not be required to submit exception requests to the Department under proposed § 160.203(a), but could provide documentation that the state law meets one of the conditions articulated in proposed § 160.203.
Response: We disagree that the process adopted at § 164.204 below will be burdensome, unwieldy, or time-consuming. The only thing the regulation describes is the showings that a requestor must make as part of its submission, and all are relevant to the issue to be determined by the Secretary. How much information is submitted is, generally speaking, in the requestor's control, and the regulation places no restrictions on how the requestor obtains it, whether by acting directly, by working with providers and/or plans, or by working with others. With respect to the suggestion that states not be required to submit exception requests, we disagree that this suggestion is either statutorily authorized or advisable. We read this comment as implicitly suggesting that the Secretary must proactively identify instances of conflict and evaluate them. This suggestion is, thus, at bottom the same as the many suggestions that we create a database or compendium of controlling law, and it is rejected for the same reasons.
Comment: Several comments urged that all state requests for non-preemption include a process for public participation. These comments believe that members of the public and other interested stakeholders should be allowed to submit comments on a state's request for exception, and that these comments should be reviewed and considered by the Secretary in determining whether the exception should be granted. One comment suggested that the Secretary at least give notice to the citizens of the state prior to granting an exception.
Response: The revision to § 160.204(a), to permit requests for exception determinations by any person, responds to these comments.
Comment: Many commenters noted that the lack of a clear and reasonable time line for the Secretary to issue an exception determination would not provide sufficient assurance that the questions regarding what rules apply will be resolved in a time frame that will allow business to be conducted properly, and argued that this would increase confusion and uncertainty about which statutes and regulations should be followed. Timeframes of 60 or 90 days were suggested. One group suggested that, if a state does not receive a response from HHS within 60 days, the waiver should be deemed approved.
Response: The workload prioritization and management considerations discussed above with respect to advisory opinions are also relevant here and make us reluctant to agree to a deadline for making exception determinations. This is particularly true at the outset, since we have no experience with such requests. We therefore have no basis for determining how long processing such requests will take, how many requests we will need to process, or what resources will be available for such processing. We agree that states and other requesters should receive timely responses and will make every effort to make determinations as expeditiously as possible, but we cannot commit to firm deadlines in this initial rule. Once we have experience in handling exception requests, we will consult with states and others in regard to their experiences and concerns and their suggestions for improving the Secretary's expeditious handling of such requests.
We are not accepting the suggestion that requests for exception be deemed approved if not acted upon in some defined time period. Section 1178(a)(2)(A) requires a specific determination by the Secretary. The suggested policy would not be consistent with this statutory requirement. It is also inadvisable from a policy standpoint, in that it would tend to maximize exceptions. This would be contrary to the underlying statutory policy in favor of uniform federal standards.
Comment: One commenter took exception to the requirement for states to seek a determination from the Department that a provision of state law is necessary to prevent fraud and abuse or to ensure appropriate state regulation of insurance plans, contending that this mandate could interfere with the Insurance Commissioners' ability to do their jobs. Another commenter suggested that the regulation specifically recognize the broad scope of state insurance department activities, such as market conduct examinations, enforcement investigations, and consumer complaint handling.
Response: The first comment raises an issue that lies outside our legal authority to address, as section 1178(a)(2)(A) clearly mandates that the Secretary make a determination in these areas. With respect to the second comment, to the extent these concerns pertain to health plans, we believe that the provisions at § 164.512 relating to oversight and disclosures required by law should address the concerns underlying this comment.
Section 160.204(a)(4) - Period of Effectiveness of Exception Determinations
Comment: Numerous commenters stated that the proposed three year limitation on the effectiveness of exception determinations would pose significant problems and should be limited to one year, since a one year limitation would provide more frequent review of the necessity for exceptions. The commenters expressed concern that state laws which provide less privacy protection than the federal regulation would be given exceptions by the Secretary and thus argued that the exceptions should be more limited in duration or that the Secretary should require that each request, regardless of duration, include a description of the length of time such an exception would be needed.
One state government commenter, however, argued that the 3 year limit should be eliminated entirely, on the ground that requiring a redetermination every three years would be burdensome for the states and be a waste of time and resources for all parties. Other commenters, including two state agencies, suggested that the exemption should remain effective until either the state law or the federal regulation is changed. Another commenter suggested that the three year sunset be deleted and that the final rule provide for automatic review to determine if changes in circumstance or law would necessitate amendment or deletion of the opinion. Other recommendations included deeming the state law as continuing in effect upon the submission of a state application for an exemption rather than waiting for a determination by the Secretary that may not occur for a substantial period of time.
Response: We are persuaded that the proposed 3 year limit on exception determinations does not make sense where neither law providing the basis for the exception has changed in the interim. We also agree that where either law has changed, a previously granted exception should not continue. Section 160.205(a) below addresses these concerns.