HIPAA - Your Rights to Health Insurance
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) created valuable new protections for millions of Americans - including those with pre-existing medical conditions - who
change jobs, become self-employed or lose their jobs.
The law provides better access to health insurance coverage; prohibits discrimination against employees and dependents based on health status; and guarantees availability and renewability of
health insurance coverage in both the group and individual markets.
Although most HIPAA provisions took effect on July 1, 1997, many consumers and employers are still not aware of the rights they have under the law provided to increase public awareness of the
protections now available.
What kinds of protections does HIPAA provide?
- HIPAA gives you portability. Prior coverage from one health plan may be used to reduce or eliminate a pre-existing condition exclusion period if you move to a new group health plan. (However,
HIPAA does not give you the right to retain the identical coverage.)
- HIPAA allows for special enrollment periods. If your spouse or other dependents have other health insurance coverage and then lose it, they may be entitled to a
special enrollment period of 30 days, during which they can sign up for your group coverage without having to wait for the plan's next open enrollment period, if it has one. New dependents, such
as newborn or adopted children, are also entitled to special enrollment period. In addition, employees who previously declined group coverage may sign up for coverage when a dependent qualifies
for special enrollment period or if they had other coverage and then lose it.
- HIPAA prohibits discrimination. In a group health plan, you or your dependents may not, generally speaking, be charged a higher premium because of any reason
related to health status.
- If a health plan participates in the small group market (employers with 2 - 50 employees), HIPAA requires that all products be sold on a guaranteed available
basis to any employer wishing to purchase them.
- In the individual market, HIPAA requires that eligible individuals, who have 18 months of prior coverage and meet certain requirements, can purchase coverage on
a guaranteed available basis from any company selling coverage in the individual market.
- HIPAA requires that all health insurance sold in all markets - large group, small group, and individual - be guaranteed renewable, with only very limited
exceptions.
- To facilitate portability, HIPAA requires that Certificates of Creditable Coverage be issued any time a person's health insurance coverage ends.
- HIPAA also guarantees other rights including protections for mothers and newborns; parity between mental health and other health benefits; and certain benefits
for mastectomy patients.
What you need to do to protect your rights in the Individual Market
- If your group health insurance ends, and your employer offers you COBRA or Cal-COBRA continuation coverage, you must elect and exhaust continuation coverage
(normally 18 or 36 months), or you may jeopardize your rights under HIPAA.
- When you know that your group health insurance, COBRA or Cal-COBRA is going to end, you should begin looking for other coverage within 63 days of the termination
of your old coverage, or you may lose your rights under HIPAA.
- If you have COBRA or Cal-COBRA coverage that is ending, make sure that you evaluate carefully your options for new coverage. Generally, you will be eligible for
guaranteed available HIPAA policy. You may be offered an individual conversion plan. You are also free to apply for any other product sold on the individual market. Be aware that HIPAA plans and
conversion plans (when offered) are guaranteed available, but you can be turned down for other types of coverage. Choose with care when you decide which coverage to buy because you may not be
able to change it later.
- If your health insurance ends for any reason, make sure you ask for a Certificate of Creditable Coverage. Your employer and/or your health plan are required to
give you one.
- Do not delay applying for other coverage while waiting for your Certificate. You may also demonstrate creditable coverage through other evidence. No company
selling health insurance can deny simply because you do not have a Certificate.
What you need to know to protect your rights in the Group Market
- If you change jobs and your new employer offers group health insurance, you may be subjected to an exclusion period of six to 12 months for pre-existing
conditions. During the exclusion period the pre-existing disease or medical condition will not be covered by your health insurance. HIPAA places restrictions on when and for how long a
pre-existing exclusion period may be imposed. Under the law, when a pre-existing exclusion period is allowed, you can reduce or totally eliminate it with prior creditable coverage. Creditable
coverage can be group coverage from your previous job, or almost any other kind of health insurance coverage, so long as it ended no more than 63 days before you became eligible for the new
group coverage. Several different period of coverage can also be added together, so long as there have been no breaks between them of longer than 63 days.
- You can prove that you have prior creditable coverage with a Certificate of Creditable Coverage. A certificate must be issued to you whenever a period of
coverage ends, but you also have the right to request a certificate at any time. In addition, you have the right to present other evidence of creditable coverage in case a certificate is not
available. - If you work for a small employer (one who has 2-50 employees), your employer has the right to purchase group health coverage on a guaranteed available basis from any company selling
in the small group market. If your employer decides to purchase coverage, every eligible employee (and dependent) has the right to apply for and be accepted by the employer's small group
coverage. |
