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Course Description

Many organizations that provide health care services also provide other services that are not related to heath care and are that not paid for by health plans or Medicaid.  For such organizations a decision must be made: Do we apply HIPAA controls and policies throughout the organization for all programs, or do we decide what parts of our organization are under HIPAA and what parts are not, and designate Hybrid Entity status under HIPAA?  There are significant impacts in making the choice to be a Hybrid Entity or not, and entities need to consider their own particular circumstances to determine the most appropriate path to take.

If one portion of an entity is covered under HIPAA, the entire entity is subject to HIPAA, unless the entity declares Hybrid Entity status and limits the sharing of information between the HIPAA and non-HIPAA portions.  Either option has its pros and cons and any entity’s choice is not obvious at first glance.  For something like a county government, it’s easy to see that while the County Nursing Home may be a HIPAA entity, it would not make sense to apply HIPAA controls to the County Highway Department, and the designation of Hybrid Entity status for the county would an obvious choice, as there is no need to share any health care information between the County Nursing Home and the County Highway Department.

But for behavioral health and social service organizations, the choice is not so clear.  To be able to share information from a HIPAA portion to a non-HIPAA portion, in a Hybrid you need to have a HIPAA Authorization from each individual served, and you must have strict logical “firewalls” between the HIPAA and non-HIPAA portions to protect information from unauthorized access.

You need to make sure any systems that carry or touch any Protected Health Information are secure no matter which model you follow; would it be easier to apply HIPAA throughout the organization?  You do, after all, have obligations to protect individuals’ privacy, ethically or under the law, whether HIPAA applies or not, and HIPAA provides a good, recognized standard for protecting the privacy and security or personal information.  And consistency within the organization is important – wherever you can reduce staff choices in how to handle information, you reduce the chances for making the wrong choice.

There are burdens associated with either choice, and the best choice depends on how you do business and how easily separable and distinct your programs are.  If there is no real overlap between HIPAA and non-HIPAA programs in services, locations, and staff, Hybrid status may make sense, but you will need to get a HIPAA Authorization if you want to refer an individual to another of your programs outside of HIPAA.  If the lines are blurred and information needs to be shared to achieve the organization’s goals, HIPAA-everywhere may be better, but it will require organization-wide policies, procedures, and training.

This session will examine the options and the issues in choosing to be a Hybrid Entity or not and assist organizations in making the decision and implementing the results of the decision.  Agencies will come away with a better understanding of how they should designate themselves and what they need to do for compliance in either case.

In This Session:

  • The definition of a HIPAA Hybrid Entity
  • Typical Hybrid Entities
  • Understanding your information flows
  • How much of your work is healthcare?
  • Requirements of not claiming Hybrid status
  • Requirements of claiming Hybrid status
  • The HIPAA Authorization issue
  • Example Hybrid Entity analyses
  • Policy and Procedure Requirements
  • Documentation and Training Requirements

Key Points:

  • Find out how to evaluate whether or not your organization is best served by Hybrid Entity status.
  • Learn how to properly declare and document Hybrid Entity status when that is the best choice.
  • Find out what policies and procedures are required, and for whom, for entities using a HIPAA-everywhere approach.
  • Find out what policies and procedures are required, and for whom, for entities using a HIPAA-Hybrid approach.
  • Learn about the training and education that must take place and be documented to ensure your staff uses health information properly and does not risk exposure of PHI.
  • Find out the steps that must be followed in the event of a breach of PHI.
  • Learn about how the HIPAA audit and enforcement activities are now being increased and how you must be prepared or risk significant penalties.

Who will benefit:

Compliance Director



Privacy Officer

Security Officer

Information Systems Manager

HIPAA Officer

Chief Information Officer

Health Information Manager

Healthcare Counsel/lawyer

Office Manager

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