What is HIPAA and What Does it Mean to Me?

Individuals with various health conditions are often reluctant to leave jobs because they are afraid pre-existing condition clauses will limit coverage of any such conditions under a new insurance plan. HIPAA (Health Insurance Portability and Accountability Act of 1996) limits the amount of time an insurer can refuse to cover pre-existing conditions to twelve months. HIPAA also ensures that in some cases there is no waiting period for new coverage. However, an insurer is still not required to cover every condition and disability. In some cases, they can still deny coverage altogether for certain conditions as long as the decision is based on sound actuarial data.State laws may offer more generous protections than HIPAA. You may want to contact your state insurance commissioner’s office to ask about the law where you live. A good place to start is the Web site of the National Association of Insurance Commissioners at www.naic.org.

A “pre-existing condition” is considered to be any condition for which medical advice, diagnosis, care or treatment was recommended or received within the previous six-month period. The maximum amount of time a plan can refuse coverage for any such condition is twelve months. If an individual starts a new job and is subject to a waiting period before being eligible to join the health plan, the waiting period and twelve-month period for the pre-existing conditions must coincide.

The twelve-month period for pre-existing conditions may also be reduced if the individual provides the new insurance plan with proof of their prior health coverage. When leaving a health plan, the plan must provide you with a Certificate of Coverage which details the dates you were covered under the plan. This continuous coverage can be credited toward the pre-existing condition period, provided there was not a “significant break” in coverage between jobs – this is defined as sixty-three days.

Therefore, if you had at least twelve months of “creditable coverage” (which can be from a group health plan, HMO, individual health insurance policy, Medicare, or Medicaid) and then left your job and you started a new job within sixty-three days thereafter, the pre-existing condition period would not apply. Your condition would be covered immediately (provided that the plan regularly covers that condition). COBRA coverage can also be credited towards continuous coverage.

HIPPA can also help provide access to individual insurance when group coverage is not an option. HIPAA guarantees access to an individual plan if: the individual had group coverage for at least eighteen months; did not have their group coverage terminated because of fraud or nonpayment of premiums; is ineligible for COBRA or has exhausted COBRA benefits; and is not eligible for coverage under another group health plan.