The Guarantor for Minors and Divorced Parents

The most useful finding about this subject is an absence. The word guarantor — and “responsible party”, and “financially responsible” — does not appear in the federal privacy rules, in the Medicare claims and payment regulations, or in the federal debt-collection rules. Across the whole Code of Federal Regulations the term resolves to corporate solvency and to debts owed to federal agencies. No federal source creates, defines or assigns the role.

That is not an oversight. Federal law here presupposes an obligation created somewhere else and regulates only how it may be collected: the debt-collection rules define a debt as an obligation arising out of a transaction, and a creditor as the person to whom it is owed. The transaction, in a practice, is the financial-responsibility agreement signed at registration.

A parent, guardian or person acting in loco parentis is the personal representative of an unemancipated minor — and therefore stands in the minor's shoes for protected health information — only where applicable law gives that person authority to make health care decisions for the minor, and only as to information relevant to that representation. HIPAA does not confer the status. It reads it off state law.

Three situations remove it, and the scoping words matter more than the situations do: when one applies, the minor acts as the individual with respect to protected health information pertaining to a health care service — the particular service that triggered it. The same parent remains the personal representative for every other encounter.

1. The minor consented to the service, no other consent was required by law — expressly “regardless of whether the consent of another person has also been obtained” — and the minor has not asked that the parent be treated as the representative.
2. The minor may lawfully obtain the service without parental consent, and the minor, a court, or another person authorized by law consented.
3. The parent assents to an agreement of confidentiality between the provider and the minor for that service. This is the one a parent creates voluntarily, on the clinical side, and the billing office is the last to hear about it.

This is where practices reason confidently from a document they have never been a party to. A medical child support order is a real instrument with real federal force, and its force runs in directions that are not the one people assume.

It can compel coverage, and give the child standing

A group health plan must provide benefits in accordance with a qualified medical child support order. The child — not the parent — is the “alternate recipient”, and is treated as a beneficiary for the statute's purposes. A properly completed National Medical Support Notice issued by the state agency is deemed to be such an order. Note where the qualification decision sits: with the plan administrator, under written procedures, rather than with a claims line.

It can redirect the plan's money

The federal reimbursement direction runs to the alternate recipient, the custodial parent or the legal guardian — and does not name the provider. Direct payment to the provider comes from a different place: a state statute enacted to meet the Medicaid condition that requires insurers to permit the custodial parent, or the provider with that parent's approval, to submit claims without the non-custodial parent's approval, and to pay the custodial parent, the provider, or the state agency. Whether a given state enacted it, and how far, is a question about that state's code.

It reallocates decision authority — which is the input HIPAA reads

This is the one genuinely useful thing a decree does for a billing office, and it is worth being honest that it is an inference rather than something the regulation states: the personal-representative rule turns on who has health care decision authority under applicable law, and a custody order is the document that allocates it. Read the decree for that, and stop there.

It does not touch the practice's contract

Nothing read makes a decree enforceable by or against a provider, gives a provider a claim against a non-signing parent, discharges the parent who did sign, or obliges the practice to enforce an allocation between parents. The words divorce, custody and child support appear nowhere in the privacy provisions that govern the rest of this article.

A covered health care provider must permit an individual to request that communications be sent by alternative means or to an alternative location, and must accommodate reasonable requests. It may not require an explanation of why. It may require the request in writing, may require specification of an alternative address, and — the clause that makes this workable — may require information as to how payment, if any, will be handled.

The one mechanism in these rules that reliably keeps an encounter away from the plan is a different provision, and it is mandatory rather than discretionary. Where the information pertains solely to an item or service for which the individual — or a person other than the health plan on behalf of the individual — has paid the covered entity in full, the entity must agree to restrict disclosure of that information to the plan for payment or operations purposes, and cannot unilaterally terminate that restriction afterwards. Note who that reaches: a parent who is not the policyholder, paying cash.

The minimum necessary standard applies to uses, disclosures and requests, and its list of exceptions is closed. It contains disclosures to the individual, disclosures made under an authorization, and a short list of others. It does not contain a carve-out for a guarantor, for a family member, or for billing.

• Where a person other than the patient is being told about the balance, the authority is either that they are the personal representative — in which case they are treated as the individual for information relevant to that representation — or that they were involved in the individual's care or in payment for that care, in which case the disclosure is capped at what is directly relevant to that involvement.
• The general permission to disclose for payment purposes does not fill the gap. Read closely, it names other covered entities and health care providers as the recipients for payment activities. A parent is neither.
• Routine statement runs are exactly what the rule calls routine and recurring disclosures, which are supposed to be governed by standard protocols rather than decided case by case — and the entire record is never the answer without specific justification.
• Where a balance is reported to a credit bureau, the permitted data elements are an enumerated, closed list: identifying details, payment history, an account number and the provider's or plan's own name and address. No diagnosis, no procedure, no clinical content of any kind.