Information Collection Requirements Referenced in HIPAA for the Group Market, Supporting Regulations 45 CFR 146, and forms/instructions (CMS-R-206)

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare

and Medicaid Services

Region VII

Federal Office Building

601 East 12^th Street, Room 235

Kansas City, Missouri 64106

RE: Missouri Group Form Review for compliance with HIPAA

Dear Sir or Madam:

As you aware, as of the date of this letter, the State of Missouri has not fully incorporated the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) into State law. As a result, pursuant to 42 USC 300gg-22 and 42 USC 300gg-45, the enforcement of HIPAA in Missouri is currently the responsibility of this office. Policy form reviews are one of the enforcement tools used by CMS in Missouri to confirm health insurance issuers’ compliance with HIPAA.

The Centers for Medicare & Medicaid Services (CMS) last requested all policy forms for review approximately three years ago. Due to the length of time since the last review, and with the recent publication of the HIPAA Group Market regulations, CMS is undertaking another review of all group policy forms issued or renewed in the State of Missouri for compliance with HIPAA.

CMS requests that your organization submit all policy forms, riders, applications as well as any other relevant material (i.e. marketing materials, etc.), to this office for review.

When responding to this request, please provide all policy forms and related materials offered in the group markets.

If you are not the correct individual to address this request, please route this correspondence to the correct individual(s) or department. Please submit all material to:

Associate Regional Administrator for Medicaid and Children’s Health Operations

Centers for Medicare & Medicaid Services

Attn: Insurance Reform Team

Richard Bolling Federal Building

601 East 12^th Street, Room 235

Kansas City, MO 64106

Please note that we are requesting the materials be sent to CMS within 30 days of the date of this letter. In circumstances in which you cannot prepare the requested materials within this time period, you may contact our office so we may discuss a reasonable extension.

Presently there is no fee imposed by CMS in the course of meeting its responsibility to review policy forms. After completing our review, we will provide you with any comments and/or recommendations. If necessary, we may arrange to meet with you and your staff to further discuss our findings and other HIPAA issues.

If discussion or clarification is desired, please contact Evan Doran of this office at (816) 426-6314. Thank you for your attention to this matter.

Sincerely,

James G. Scott

Associate Regional Administrator for Medicaid and

Children’s Health Operations

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0938-0702. The time required to complete this information collection is estimated to average 20 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate (s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attention: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

(CMS-R-206)

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