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This topic presents common questions and answers about Health Insurance Reform provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) from a consumer's perspective.
You can read through the topic in sequence, or jump directly to questions in one of the sections listed below:
· About Pre-Existing Condition Exclusions
· About Access to Other Coverage Options
1) Are there any situations in which exclusions are completely prohibited?
Under HIPAA's group market rules, there can be no pre-existing condition exclusion for pregnancy, no matter when pregnancy began and whether medical advice, diagnosis, care, or treatment was recommended or received for the pregnancy. An exclusion cannot be applied to you even if your previous health plan did not cover pregnancy.
An exclusion cannot be applied just because there is genetic information suggesting that you may have a particular condition.
An exclusion cannot be applied at all to a child who was covered by creditable coverage no later than 30 days after birth or after being adopted or placed for adoption with you.
2) I had a pre-existing condition exclusion period at my prior employment. Can another exclusion period be applied by my new group health plan?
It depends on how much creditable coverage you have. If you were subject to a pre-existing condition exclusion period in the past, it does not itself prevent you from having another one applied now. If you only have a little creditable coverage, a pre-existing exclusion period may still apply to your new coverage.
3) I am changing from one type of coverage to another, but staying within the same employer's group health plan. Can a pre-existing condition exclusion be applied to my new coverage?
It depends on how long you have been in the group health plan. If you sign up at the first opportunity, a pre-existing condition exclusion cannot extend more than 12 months after your enrollment date. Your enrollment date is the first day on which you are able to receive benefits under a group health plan or, if your plan imposes a waiting period, the enrollment date is the first day of your waiting period - typically your date of hire.
If less than 12 months have passed, a pre-existing condition exclusion might be applied, but the exclusion cannot last beyond the one-year anniversary of your enrollment date (a total of 12 months).
See below for examples of exclusions in several situations.
Nancy began work on June 1, 1999. She signed up for her employer's group health plan on the same day, as soon as she was eligible to do so. Her employer has no waiting period, so she was able to receive benefits as soon as she signed up. As a result, June 1, 1999 is her enrollment date.
On May 1, 2000, Nancy changed from one coverage option available under the plan to another. Because 12 months had not passed since her enrollment date, a pre-existing condition exclusion might be applied to her new coverage option. The exclusion can only be effective, however, until June 1, 2000.
If an exclusion is applied, it will be reduced one day for each day of creditable coverage that you have as of your enrollment date.
Betty began work on June 1, 1999 and signed up for her employer's group health plan at the first opportunity. She has no waiting period. As of her enrollment date (June 1, 1999) she has a total of 60 days of creditable coverage from a previous employer. On May 1, 2000, at the first opportunity to do so, Betty changes from one coverage option available under the plan to another. Without taking her creditable coverage into account, the pre-existing condition exclusion period would end on June 1, 2000 (with 30 days remaining). Her 60 days of creditable coverage are enough to eliminate the entire remaining exclusion period. As a result, no exclusion can be applied to her new coverage option.
If more than 12 months have passed since your enrollment date, a pre-existing condition exclusion cannot be applied to your new coverage.
Dan began work for his current employer on March 1, 1999. He signed up for his employer's group health plan on the same day, as soon as he was eligible to do so. He has no waiting period. As a result, March 1, 1999 is his enrollment date. On April 10, 2000, Dan changed from one coverage option available under the plan to another. Because more than 12 months have passed since his enrollment date, no pre-existing condition exclusion can be applied.
4) I've lost my job but I haven't found a new one yet. What can I do to retain my protections under HIPAA?
Be careful to avoid a significant break in coverage (63 or more full days in a row without any coverage). If offered, decide whether you should accept COBRA continuation coverage. If you had group health plan coverage at your last job, you probably will be offered COBRA continuation coverage (or similar continuation coverage that must be offered to you under State law). If you are eligible for such continuation coverage, it counts as creditable coverage. In addition, you must accept and exhaust COBRA benefits before you can obtain coverage in the individual market as a HIPAA eligible individual. (You may also have to satisfy other requirements to obtain the coverage.)
5) What events trigger a special enrollment period?
Special enrollment is required in two situations:
a) You or your dependent lose other health coverage; and
b) You get a new dependent through marriage, birth, adoption, or placement for adoption with you.
To get a special enrollment opportunity in this situation, the employee or dependent must earlier have turned down coverage available through the group health plan because he or she had other coverage.
If the other coverage was COBRA continuation coverage, special enrollment can be requested only after the COBRA coverage is exhausted.
If the other coverage was NOT COBRA continuation coverage, the individual can request special enrollment when his/her other coverage ends because the individual is no longer eligible for it.
A special enrollment period also must be given if the employer sponsoring the group health plan stops paying its share of the premiums.
If the triggering event is a birth, adoption or placement for adoption, the child, the employee, and the employee's spouse are entitled to special enrollment, either individually or in any combination.
6) When do I request special enrollment?
If a special enrollment period is triggered when an employee or his/her dependent loses other health coverage, the employee must request the special enrollment(s) within 30 days of the loss of coverage. If a special enrollment period is triggered when a new dependent is added, the individual must request the special enrollment(s) within 30 days of the triggering event.
7) How are pre-existing condition exclusions applied to special enrollees?
For each triggering event, a special enrollee is regarded as a regular enrollee and not a late enrollee. Therefore, the maximum pre-existing condition exclusion period that may be applied to a special enrollee is 12 months. The 12 months are reduced, day for day, by the special enrollee's creditable coverage. In addition, a newborn, adopted child or child placed for adoption cannot be subject to a pre-existing condition exclusion period if the child is enrolled within 30 days after birth, adoption or placement for adoption and has no subsequent significant break in coverage after that time.
8) Are plans and issuers required to notify individuals of their special enrollment rights?
Yes. A notice of special enrollment rights must be provided to employees on or before the time they are offered the opportunity to enroll in the group health plan.
9) When will the new coverage start?
When the individual loses other coverage, the new coverage must begin no later than the first day of the first calendar month beginning after the date the employee requests special enrollment.
In the case of marriage, enrollment must be effective not later than the first day of the first calendar month that begins after the date the group health plan receives the completed request for enrollment.
In the case of birth, adoption, or placement for adoption, enrollment is required to be effective not later than on the date of such birth, adoption, or placement for adoption.
10) What if I don't receive a certificate, or lose one that I received?
In most cases, your first step should be to contact the plan administrator of your prior group plan. Ask for a copy of the certificate; it should be free of charge. If you do not automatically receive a certificate of coverage or receive one before you need it, you should:
a) Contact the plan administrator if you have been in a group plan; or
b) Contact the health insurance issuer if you have had individual coverage.
Because some people have had creditable coverage through multiple sources, you should always check with all sources to be sure you get the credit you deserve.
If you lose your certificate, you can go back and request another one, free of charge. In most cases, even if you do not receive a certificate, you can use other evidence to prove creditable coverage. These include:
a) Pay stubs that reflect a premium deduction;
b) Explanation of benefit forms;
c) A benefit termination notice from Medicare or Medicaid; and
d) Verification by a doctor or your former health care benefits provider that you had prior health coverage.
You also can request a certificate describing your coverage under a particular group health plan, policy or contract (free of charge) at any time while you are still covered or up to 24 months after the coverage has ended. Each certificate that you request should describe the creditable coverage you have received for the prior 24 months.
See the HIPAA - Insurance Reform Model Certificate topic for an example of the type of information that should be included on a certificate.
11) What are the circumstances in which I will have portability?
HIPAA provides for portability rights in three circumstances:
a) When you leave a job where you had group health plan coverage, and move to another job with group health plan coverage. (This also applies if you are covered as a dependent of the person who changes jobs.)
b) You lose group health plan coverage, you meet the definition of a HIPAA eligible individual, and you wish to purchase individual health insurance coverage.
c) You have individual health insurance coverage or any other type of creditable coverage, and you enroll in a new group health plan.
12) What does portability NOT do?
There are three things that portability does NOT do.
a) Portability does NOT let you keep your current plan or benefits when you change or lose your job or get a new job.
b) It does NOT require your new employer or union to provide health coverage.
c) It does NOT guarantee that if you move from one plan or policy to another, the benefits you receive will be the same as those that were available to you under your old plan or policy. Coverage under the new plan could be less (or more) generous, and premiums and cost-sharing arrangements (such as deductibles and copayments) may differ.
HIPAA does NOT provide for portability rights when you have individual health insurance coverage and you move to other individual health insurance coverage. However, State law might provide portability rights in this situation.
13) I've lost my job, and I am worried about health insurance. Is there any help for me?
You may have rights to certain health coverage even if you lose your job. If your company provided a group health plan, you may be entitled to continued health benefits for a period of time under COBRA or a State law. You may also have rights under HIPAA to buy individual health insurance.
14) If I had health coverage under my or my spouse's old job but I lost that coverage and do not have access to group coverage through my new job, can HIPAA help me as an individual?
If you meet the requirements to be a HIPAA eligible individual, you must get a choice of individual coverage with no pre-existing condition exclusion, either through a health insurance issuer or a State's high-risk pool.
15) Can I keep my doctor?
If you are changing from one health plan to another, or from one policy to another, you may have to change doctors. It depends on the benefits offered by your new plan or policy. Your need to change doctors is especially true if you join a managed care plan. Check with your plan to understand the extent your choice of doctors may be restricted.
16) Do HIPAA's group market protections apply to all group health plans?
No, HIPAA's group market protections do not automatically apply to all employment-related group health plans. The following situations trigger some exceptions:
a) Very small plans. In most cases, if you are in a group health plan that only covers one current employee, State law will determine whether you have HIPAA group market protections. Check with your State insurance department to find out if HIPAA group market protections apply to you.
b) Non-federal governmental plans. If your eligibility for your group health plan is based on your or someone else's employment with a State or local government agency, HIPAA protections should apply to you unless your plan has notified you that it is exempt from some or all HIPAA requirements. However, even if the plan is exempt from other requirements, it must always provide you with a certificate of creditable coverage when your coverage ends. You also can ask your plan administrator if you are not sure which protections apply.
c) Federal governmental plans. If your eligibility for your group health plan is based on your or someone else's employment with a Federal government agency, HIPAA itself does not apply directly, but the government affords similar protections.
d) Church plans. If your eligibility for your group health plan is based on your or someone else's employment with a church or group of churches, you should check with your plan administrator to find out whether HIPAA's group market protections apply to you.
17) Does HIPAA limit my health insurance premiums?
HIPAA generally does not limit premiums. However, when a plan or issuer provides group health plan coverage, HIPAA does not allow the plan or issuer to charge one individual a higher premium based on that individual's health status. For example, individuals with diabetes cannot be charged a higher premium because of that medical condition. An individual must be charged the same premium that is charged to similarly situated individuals for the same coverage. Similarly situated individuals are, for example, other individuals who are in the same employee category, or in the same geographic location. Employee categories may include, for example, full-time employees (or part-time employees), all employees with the same length of service, and current employees (or former employees). Employees' dependents are grouped into categories that are based on the categories used for the employees themselves. For example, if employees are categorized by location, as full-time or part-time, all dependents of part-time employees are similarly situated individuals.
The HIPAA Insurance Reform Employer FAQ topic provides information in a question and answer format, similar to this topic, from an employer's perspective.
See the HIPAA Insurance Reform Overview topic for additional information about the Insurance Reform provisions of HIPAA.
See the HIPAA - Insurance Reform Model Certificate topic for an example of the type of information that should be included on a certificate.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) - Overview
Information in this topic was drawn from pages of the Centers for Medicare & Medicaid Services' Health Insurance Portability and Accountability Act of 1996 (HIPAA) website at:
http://www.cms.hhs.gov/HealthInsReformforConsume/
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