3-Hour Virtual Seminar on HIPAA vs. SAMHSA 42 CFR Part 2: Managing Disclosures when Substance Use Disorders are Involved

Duration: 3 Hours
Instructor: Jim Sheldon Dean
Webinar Id: 801630


One Attendee
Unlimited Attendees ?

In this webinar the latest guidance from the US Department of Health and Human Services on harmonization of SAMHSA and HIPAA will be explained, We will discuss what qualifies treatment that falls under SAMHSA, HIPAA allows a number of disclosures, for treatment, payment, and healthcare operations purposes, without consent from the individual being treated, also We will examine how to deternmine if the services you provide place you under 42 CFR Part 2.


This session focuses on the issues of managing health information when it may involve substance use disorder treatment information. HIPAA allows a number of disclosures without consent that SAMHSA prohibits without consent.

First we will explain how HIPAA relates to information management and release and explain the processes required for various releases of information under the HIPAA rules, including release according to individual access requests, and under HIPAA authorizations.

When substance use disorder treatment information is involved, first you need to understand how to identify it. We will discuss how to make it distinguishable from "regular" health information, so that the appropriate extra protections can be provided. You may be able to use functions in your EHR to flag the information, or you may create a manual process for tracking the information, if it is rarely handled in your organization. And the substance use disorder treatment information you collect may or may not be under SAMHSA depending on whether or not you have a department or even a response team that specializes in SAMHSA-related situations. You need to understand your status under the rules before you release information inappropriately. We will discuss what qualifies treatment that falls under SAMHSA.

If your organization provides services that create information that is under the SAMHSA regulations, you will need to establish the consent and release of information processes that are required to be followed for information releases under 42 CFR Part 2. This involves getting the proper consents upon establishment of the relationship, as well as managing consents for releases that may be necessary after the initial establishment of the relationship. The session will include an explanation of the consent and release requirements that must be followed.

When you release information under HIPAA, there are no special notices required to be placed on the records. But when you release information under SAMHSA, each document must have a notice that explains that re-disclosure is not permitted without a new consent. Complicating matters are updated rules going into effect that will allow a consent that permits a re-release to a defined team of providers caring for the individual, but then require meticulous documentation of to whom the information has been released under such a consent.The session will go over the rules on consents and re-release of information.

With the current epidemic of opioid abuse, there has been a great deal of publicity around the release of information and the necessity to share information with family and friends to facilitate recovery, but the rules remain in place as is. HIPAA allows such releases under some circumstances, while a consent is required under 42 CFR Part 2.HHS has issued guidance on how to deal with the regulations in the face of the crisis, but the inconsistencies and difficulties remain. In this session we will review the guidance and learn how it helps explain some of the rules.

In addition, the session will review the processes used for and some of the enforcememt settlements reached in the reporting of breaches under HIPAA, as well as proposals to further harmonize HIPAA and 42 CFR Part 2, including the levying of HIPAA-level penalties for violations of the Part 2 rules. The latest proposals to modify the Part 2 rules and their potential impacts will be discussed.

Overall, substance use disorder treatment information can complicate your records management and release processes, but by recognizing and planning for the issues, you can minimize the impacts.

Why should you Attend: Today we are in the midst of an epidemic of substance use disorders, and particularly opioid abuse, and more and more providers are involved in providing treatment to people with substance use disorders. When substance use disorders are involved, the rules of SAMHSA under 42 CFR Part 2 come into play. But who is covered under the rules, what’s involved in meeting them, and how do they interact with HIPAA? HIPAA allows a number of disclosures, for treatment, payment, and healthcare operations purposes, without consent from the individual being treated.

SAMHSA rules, on the other hand, require consent for every disclosure or re-disclosure, and if the proper consents aren’t obtained, the provider can be in violation of the rules and subject to penalties.

Not every provider that treats a person with substance abuse issues automatically falls under the SAMHSA rules, and not all mental health information is necessarily substance abuse information. How do you know whether or not your services put you under the SAMHSA regulations? If you are under 42 CFR Part 2, how do you identify and keep separate the substance abuse information?

When a provider receives health information about an individual, under HIPAA the provider may re-disclose the information as needed for treatment, payment, and healthcare operations purposes. Information may be received, however, that has a special notice on it about re-disclosure, requiring consent from the individual before re-disclosure. Even though you may not operate under SAMHSA rules, you have obligations to respect the SAMHSA consent requirements. How can you make sure information is only shared appropriately and is not released contrary to the rules?

Areas Covered in the Session:

  • What HIPAA allows, what SAMHSA requires, and the differences will be explained
  • We will examine how to deternmine if the services you provide place you under 42 CFR Part 2
  • We will explore the means for making sure substance use disorder treatment information receives the appropriate protections
  • The consent and release requirements under 42 CFR Part 2 will be explained
  • Re-release of information released under 42 CFR Part 2 will be discussed
  • Sharing of information with family and friends in an overdose incident will be explored
  • The latest guidance from the US Department of Health and Human Services on harmonization of SAMHSA and HIPAA will be explained
  • Enforcement of the rules and the handling of breaches of information will be explained

Who Will Benefit:
  • Compliance Director
  • CEO
  • CFO
  • Privacy Officer
  • Security Officer
  • Information Systems Manager
  • HIPAA Officer
  • Chief Information Officer
  • Health Information Manager
  • Healthcare Counsel/Lawyer
  • Office Manager

Speaker Profile
Jim Sheldon-Dean is the founder and director of compliance services at Lewis Creek Systems, LLC, a Vermont-based consulting firm founded in 1982, providing information privacy and security regulatory compliance services to a wide variety of health care entities.

Sheldon-Dean serves on the HIMSS Information Systems Security Workgroup, has co-chaired the Workgroup for Electronic Data Interchange Privacy and Security Workgroup, and is a recipient of the WEDI 2011 Award of Merit. He is a frequent speaker regarding HIPAA and information privacy and security compliance issues at seminars and conferences, including speaking engagements at numerous regional and national healthcare association conferences and conventions and the annual NIST/OCR HIPAA Security Conference in Washington, D.C.

Sheldon-Dean has more than 30 years of experience in policy analysis and implementation, business process analysis, information systems and software development. His experience includes leading the development of health care related Web sites; award-winning, best-selling commercial utility software; and mission-critical, fault-tolerant communications satellite control systems. In addition, he has eight years of experience doing hands-on medical work as a Vermont certified volunteer emergency medical technician. Sheldon-Dean received his B.S. degree, summa cum laude, from the University of Vermont and his master's degree from the Massachusetts Institute of Technology.

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