Preexisting Condition Covered Under HIPAA???

U.S. Department of Labor Employee Benefits Security Administration December 2004

The Health Insurance Portability and Accountability Act (HIPAA) offers protections for millions of American workers that improve portability and continuity of health insurance coverage.

Limiting exclusions for preexisting medical conditions (known as preexisting conditions). Providing credit against maximum preexisting condition exclusion periods for prior health coverage and a process for providing certificates showing periods of prior coverage to a new group health plan or health insurance issuer. Providing new rights that allow individuals to enroll for health coverage when they lose other health coverage, get married or add a new dependent. Prohibiting discrimination in enrollment and in premiums charged to employees and their dependents based on health status-related factors. Guaranteeing availability of health insurance coverage for small employers and renewability of health insurance coverage for both small and large employers. Preserving the states’ role in regulating health insurance, including the states’ authority to provide greater protections than those available under federal law. Preexisting Condition Exclusions

The law defines a preexisting condition as one for which medical advice, diagnosis, care, or treatment was recommended or received during the 6-month period prior to an individual’s enrollment date (which is the earlier of the first day of health coverage or the first day of any waiting period for coverage). Group health plans and issuers may not exclude an individual’s preexisting medical condition from coverage for more than 12 months (18 months for late enrollees) after an individual’s enrollment date. Under HIPAA, a new employer’s plan must give individuals credit for the length of time they had prior continuous health coverage, without a break in coverage of 63 days or more, thereby reducing or eliminating the 12-month exclusion period (18 months for late enrollees). Creditable Coverage

Includes prior coverage under another group health plan, an individual health insurance policy, COBRA, Medicaid, Medicare, CHAMPUS, the Indian Health Service, a state health benefits risk pool, FEHBP, the Peace Corps Act, or a public health plan.

Certificates of creditable coverage must be provided automatically and free of charge by the plan or issuer when an individual loses coverage under the plan, becomes entitled to elect COBRA continuation coverage or exhausts COBRA continuation coverage. A certificate must also be provided free of charge upon request while you have health coverage or anytime within 24 months after your coverage ends. Certificates of creditable coverage should contain information about the length of time you or your dependents had coverage as well as the length of any waiting period for coverage that applied to you or your dependents. For plan years beginning on or after July 1, 2005, certificates of creditable coverage should also include an educational statement that describes individuals' HIPAA portability rights. A new model cerfiticate is available on EBSAs Web site. If a certificate is not received, or the information on the certificate is wrong, you should contact your prior plan or issuer. You have a right to show prior creditable coverage with other evidence — like pay stubs, explanation of benefits, letters from a doctor — if you cannot get a certificate. Special Enrollment Rights

Are provided for individuals who lose their coverage in certain situations, including on separation, divorce, death, termination of employment and reduction in hours. Special enrollment rights also are provided if employer contributions toward the other coverage terminates. Are provided for employees, their spouses and new dependents upon marriage, birth, adoption or placement for adoption. Discrimination Prohibitions

Ensure that individuals are not excluded from coverage, denied benefits, or charged more for coverage offered by a plan or issuer, based on health status-related factors.

This fact sheet has been developed by the U.S. Department of Labor, Employee Benefits Security Administration, Washington, DC 20210. It will be made available in alternate formats upon request: Voice phone: 202.693.8664; Text telephone: 202.501.3911. In addition, the information in this fact sheet constitutes a small entity compliance guide for purposes of the Small Business Regulatory Enforcement Fairness Act of 1996.

What is the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?
HIPAA’s is a federal law that:

Limits the ability of a new employer plan to exclude coverage for preexisting conditions;
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Provides additional opportunities to enroll in a group health plan if you lose other coverage or experience certain life events;
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Prohibits discrimination against employees and their dependent family members based on any health factors they may have, including prior medical conditions, previous claims experience, and genetic information; and
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Guarantees that certain individuals will have access to, and can renew, individual health insurance policies.

HIPAA is complemented by state laws that, while similar to HIPAA, may offer more generous protections. 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.

One of the most important protections under HIPAA is that it helps those with preexisting conditions get health coverage. In the past, some employers’ group health plans limited, or even denied, coverage if a new employee had such a condition before enrolling in the plan. Under HIPAA, that is not allowed. If the plan generally provides coverage but denies benefits to you because you had a condition before your coverage began, then HIPAA applies. . . (MORE)

http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

I remember when Clinton signed this into law. It impacted me and a portion of my job as I was recruiting college students for our company. I do not recall all the politics behind the bill, but it seems to me that Clinton did not want to have AIDS patients not get insurance. I think Clinton was appealing to the Gay Community.

Most of what Obama has said about bashing the insurance companies because they would not take people with pre-existing conditions appears to be pure unadulterated BS.

In my experience as a health insurance broker, here's how it works. If you have a lapse in coverage longer than 60 days between jobs, that's the only time you can get pre-exed. And only for the treatment of that particular illness for 12 months. After 12 months of paying in, your covered no matter what you have assuming you've lapsed. It's based on the theory that you will get another job within 60 days of a lapse. The key is if coverage has officially lapsed, but you have options to continue coverage either through COBRA or buying an individual policy that falls under HIPPA. Those are peoples options if they have the money to float their premiums between jobs. It's definitely a motivator to stay working.

No pre-ex for Rx's you take that treat the illness and for a few other things like pregnancy.

It applies to group major med plans, so it depends if your employer offers benefits and what policies they have. This is for workers. If you're too old to work, you get medicare. Everybody else, medicaid and other state specific plans. It's very involved depending on individual circumstances, but that's it in a nutshell.

Addendum, HIPPA applies to most group health insurance plans if an employer offers one. Employers have tax incentives to offer plans but it's still not cheap. An employers key motivators in offering benefits plans is recruiting and retention of good employees.

Like I said, it's complicated...so that's why it takes getting licensed with mandated continuing education every two years to even sell insurance. Health insurance is one of the most heavily regulated industries so it's why you have brokers, agents, and HR Departments.

Assuming ObamaCare passes, HR Departments will get alot bigger, but the brokers and agents will shrink. I'm getting ready to get legislated out of business most likely.

I have personal experience with HIPAA. There are loops to be jumped through, and deadlines to be met, so it doesn’t apply to everyone. Essentially, if you’ve had prior group coverage, you elect COBRA coverage and use ALL OF IT, then HIPAA requires any insurer in your state that writes individual policies to issue you a policy without a pre-existing condition exclusion. They can, however, charge you a rate that reflects their increased risk.

It also covers job moves from one company to another. HIPAA gets very little publicity, and I’m constantly surprised at the number of people who end up without insurance because they don’t find out about it. It is, by the way, part of Teddy Kennedy’s legacy.

Some of the Democrat scare stories involve those who had no prior coverage, so HIPAA wouldn’t cover them, but many don’t.

HIPAA applies if you lose your job and you were covered by your employers health plan. You have to elect COBRA coverage and exhaust it, then you have to make timely application for the individual policy. It’s a little advertised secret. Most employers, insurance companies, and sales people won’t tell you about it. In the past, there’ve been reports of some insurance folks playing games with the requirements to finesse people out of using it.

COBRA is for employees of companies who have 20 or more employees for more than 50% of the working days in the year who have current group health plans.

By FEDERAL LAW all of those employers are REQUIRED to inform an ex-employee of their rights under COBRA. Failure to do so carries fines.

No agent or employer meeting those requirements “hides” these benefits from employees.

I’m a broker and get asked this question quite often by people. All employees who leave a job, unless fired for cause such as theft, have the right to continue coverage.

Most employees don’t do so as they find out that they must pay the full premium that the employer has been mostly paying for them.

There has been in the past additonal help from the Federal Gov in having the employer pay for the coverage for an addtional 9 months for which the employer is supposed to get a tax credit.

One of the most important questions that insurance agents are required to ask the client and is on ALL of the insurance applications is if the application is on COBRA or if they were eligible and turned it down or declined coverage.

So to say the employers or insurance agents “hide” this is incorrect.

You might want to review my comment, which was about HIPAA coverage, not COBRA. I’ve sat in seminars with dozens of people who received no notification whatsoever about their rights under HIPAA, and about the necessity to elect COBRA coverage in order to protect those rights.

In addition, one of the labor organizations I belonged to has compiled a series of complaints from people who’d been convinced to obtain individual coverage, which was then rhetroactively cancelled shortly after the HIPAA “shall issue” window closed. It was a common enough story that it’d take a major suspension of belief to conclude it wasn’t intentional.

In my own HIPAA experience with a major insurer, I filed an application for individual coverage, checking the box that requested a policy under the HIPAA provisions in the event I failed to qualify. When I didn’t meet their underwriting standards, they coveniently “overlooked” my shall issue request. Fortunately, I noticed within the window, and submitted a new request.

I don’t doubt your assertions about COBRA, but that wasn’t what I was referring to.

If you make application within the window after you’ve used up your COBRA, and if they write individual policies in your state, they have to take you — bum ticker or no. They address the increased risk of a big pay-out by charging higher premiums, which is appropriate since there’s no free lunch, but they have to take you. It’s a Federal mandate.

The real catch is you have to use up your COBRA. If you decide to get an individual policy during the COBRA period, you lose your HIPAA qualification.

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