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HIPAA and Texas State Law Compliance

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PRESENTATION OUTLINE

HIPAA Compliance

HIPAA and Texas State Law Compliance

Hipaa

Health Insurance Portability & Accountability Act
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Medical Record Privacy Act
AND
Identity Theft Enforcement & Protection Act

Tthese are the two primary TX Acts: TMRPA under the Health and Safety Code at Chapter 181 and ITEPA under Business and Commerce Code at Chapter 521

other state laws affect both of these
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Federal HiPAA Regs

Texas Law

HIPAA

ACTS AS THE FLOOR, THe Minimum
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Pre-empts if More Stringent

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http://hipaanews.org/

Both Federal and State Laws Continue to Change

Are You a Covered Entity?
Yes, if you
Collect
Store
Use or Disclose
Transmit or
Destroy
PHI or SPI

But We're NonProfit

It doesn't matter . . .

PHI & SPI

Protected Health Information & Sensitive Personal Information
As a Covered Entity, you must abide by HIPAA and State Laws to protect PHI and SPI
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Protected Health Information:
Individually Identifiable Physical & Mental Health or Condition

Includes payment and the provision of healthcare

and past present and future health and conditions
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Sensitive Personal Info
PHI or Financial Info

Means an individual's first name or first initial and last name in combo w/ any one or more of the following items, if the name and items are not encrypted: SSN, Drivers License # or Gov't issued ID, account # or Credit or Debit Card number w/ any required security access code or password; or information that identifies a person and relates to PHI
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Privacy & Security

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Privacy Rule

Oral, Paper and Electronic Info
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Security Rule

Protection of Electronic PHI & SPI
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Security Rule

Protection of Electronic PHI & SPI
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Privacy Policies

and Procedures and Training
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Privacy

  • Identify PHI and SPI
  • Minimum Necessary Use
  • Safeguarding PHI and SPI
  • No release w/o consent
  • Sanctions
  • Retention and Destruction

Identify PHI & SPI

  • How do you collect & use it?
  • How do you safeguard it in all forms: oral, written, electronic

Minimum Necessary Use

  • Use by consent only
  • Use for purpose intended
  • No further disclosure
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Safeguarding

  • Conversations
  • Secure storage
  • Proper Destruction
  • Careful Transmission

No Release w/o Consent

Except in limited necessary circumstances
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Sanctions

if policy is violated
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Retention & Destruction

  • Maintain PHI and SPI as necessary
  • Destroy by shredding, erasing, or other means so that the info is unreadable

Workforce Training

  • Within 90 days of new hire
  • Signed verification of completion
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Workforce Training

  • Every two years
  • Within one year if a material change in the law occurs
Texas law mandates training regarding PHI at least every two years, but more often is advisable.

If the duties of an employee are affected by a material change in state or federal law concerning PHI, the employee will receive training within a reasonable period but not later than the first anniversary of the dat the material change in law takes effect.

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