Skip to main content


U.S. flag
      An official website of the United States government
              Here’s how you know
        Here’s how you knowDot gov**Official websites use .gov**
                 A **.gov** website belongs to an official government organization in the United States.
                  HTTPS**Secure .gov websites use HTTPS**
                 A **lock** (A locked padlock) or **https://** means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites. 
  Menu Close
          Enter the terms you wish to search for.
    Search
        








  
  
    

  
      

                                      About HHS
    
                        
                              
      
      
      Programs & Services
    
                        
                              
      
      
      Grants & Contracts
    
                        
                              
      
      
      Laws & Regulations                  
Health Information Privacy
  HIPAA for Individuals
    
                        
                                            
      
      
      Filing a Complaint
    
                        
                                            
      
      
      HIPAA for Professionals
    
                        
                                            
      
      
      Newsroom

              

    



Breadcrumb
    HHS
                              HIPAA Home
                              For Professionals
                              FAQ
                              1040-May a Medicaid state agency and a Medicare Advantage plan share PHI to identify dually eligible enrollees


    

    

    Navigate to:
  Authorizations (30)
          Business Associates (41)
          Compliance Dates (2)
          Covered Entities (14)
          Decedents (9)
          Disclosures for Law Enforcement Purposes (5)
          Disclosures for Rule Enforcement (1)
          Disclosures in Emergency Situations (2)
          Disclosures Required by Law (6)
          Disclosures to Family and Friends (28)
          Disposal of Protected Health Information (6)
          Facility Directories (7)
          Family Medical History Information (3)
          FERPA and HIPAA (10)
          Group Health Plans (3)
          Incidental Uses and Disclosures (10)
          Judicial and Administrative Proceedings (8)
          Minimum Necessary (14)
          Notice of Privacy Practice (20)
          Preemption of State Law (10)
          Privacy Rule: General Topics (12)
          Protected Health Information (2)
          Public Health Uses and Disclosures (13)
          Research Uses and Disclosures (20)
          Right to an Accounting of Disclosures (8)
          Right to File a Complaint (1)
          Right to Request a Restriction (4)
          Safeguards (13)
          Security Rule (24)
          Smaller Providers and Businesses (145)
          Student Immunizations (8)
          Transition Provisions (3)
          Treatment, Payment, and Health Care Operations Disclosures (30)
          Workers Compensation Disclosures (5)
          Limited Data Set (6)
          Marketing (17)
          Marketing - Refill Reminders (16)
          Personal Representatives and Minors (12)
          Right to Access and Research (58)
          Mental Health (35)
          Health Information Technology (41)
          Telehealth (11)Text resize icon

                    




May a Medicaid state agency and a Medicare Advantage plan share protected health information to identify dually eligible enrollees?








  
  
    

  
      





Answer:

Yes. The HIPAA Privacy Rule permits a covered entity to disclose protected health information (PHI) both for its own payment purposes, as well as for the payment purposes of another covered entity that receives the information. See 45 CFR 164.506(c)(3). The Privacy Rule defines “payment” to include activities to determine eligibility or coverage of enrollees. See the definition of “payment” at 45 CFR 164.501, paragraph (2)(i). Thus, a Medicaid State agency and a Medicare Advantage plan may disclose to each other PHI about their enrollees to identify those enrollees that are dually eligible under both plans. Such disclosures must comport with the Privacy Rule’s minimum necessary standard, where applicable. See 45 CFR 164.502(b), 164.514(d). In general, an electronic inquiry and response from one health plan to another to obtain information regarding the eligibility of an enrollee to receive health care must be done using the HIPAA standard transaction for eligibility (X12N 270/271 transaction). Where the disclosures between the State Medicaid agency and the Medicare Advantage plan are conducted using the standard, the Privacy Rule’s minimum necessary requirements do not apply to the disclosures of the data elements required or situationally required by the standard transaction. In contrast, where the disclosures are made outside of a standard transaction, both the Medicare Advantage plan in its request for PHI, as well as the State Medicaid agency in its response, must make reasonable efforts to limit the PHI requested and disclosed to the minimum necessary PHI for the purpose of identifying dually eligible enrollees. Because the Medicare Advantage plan must limit its request to the minimum necessary PHI to identify dually eligible enrollees, the State Medicaid agency may rely, if reasonable, on that request for PHI as satisfying the minimum necessary requirement for these purposes. See 45 CFR 164.514(d)(3)(iii).

                    
  


Content created by Office for Civil Rights (OCR) Content last reviewed July 26, 2013Back to top
    Contact HHS
    
                        
                                            
      
      
      Careers
    
                        
                                            
      
      
      HHS FAQs
    
                        
                                            
      
      
      Nondiscrimination NoticeHHS Archive
    
                        
                                            
      
      
      Accessibility Statement
    
                        
                                            
      
      
      Privacy Policy
    
                        
                                            
      
      
      Viewers & PlayersBudget/Performance
    
                        
                                            
      
      
      Inspector General
    
                        
                                            
      
      
      Web Site Disclaimers
    
                        
                                            
      
      
      EEO/No Fear ActFOIA
    
                        
                                            
      
      
      The White House
    
                        
                                            
      
      
      USA.gov
    
                        
                                            
      
      
      Vulnerability Disclosure Policy
        Sign Up for Email Updates

Receive the latest updates from the Secretary, Blogs, and News Releases.

Sign Up
  HHS Headquarters
          200 Independence Avenue, S.W.
                  Washington, D.C. 20201
                  Toll Free Call Center: 1-877-696-6775​