Health Insurance Portability in Illinois

The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996, primarily to ensure continued health coverage for individuals who switch jobs or lose employment. HIPAA achieves the goal of making coverage "portable" by limiting pre-existing condition exclusions and waiting periods, as well as eligibility restrictions based on health status. This federal law is enforced at the state level whenever a health insurer denies an individual's rights under HIPAA. To provide similar protections for Illinois small employers who want to switch insurance carriers, the Illinois Health Insurance Portability and Accountability Act was enacted in 1997.

Benefits of HIPAA

• Individuals who lose group coverage and meet all eligibility requirements can count on HIPAA to protect them. Health plans can't exclude coverage for any pre-existing conditions or make you wait until a certain exclusion period has passed.

  When your coverage under a group health plan ends, you must be provided with a "certificate of creditable coverage" that includes the start/end dates of coverage. This will enable you to obtain insurance coverage more easily through your next provider.

  If you start a new job that provides health benefits, you'll be allowed to enroll without waiting for the next open enrollment period. Instead, HIPAA entitles you to a special enrollment exception, so you can enroll any time. And for those not eligible for group coverage, HIPAA guarantees access to individual policies through the Illinois Comprehensive Health Insurance Plan (CHIP), which also ensures the renewability of individual policies.

Creditable Coverage

• To obtain a certificate of creditable coverage, you (or your family members) must have been insured for at least 18 months under one of the following types of health coverage:

  - Group health insurance plans (including COBRA)

  - Individual health insurance plans (including short-term, non-renewable policies)

  - Medicaid

  - Medicare Part A or B

  - Health care programs for members of the military

  - Health care programs for tribal organizations (including Indian Health Service)

  - State high-risk pools

  - Health plans for federal government employees

  - Public health plans

  - Health plans for Peace Corps volunteers

HIPAA Eligibility

• According to the Illinois attorney general's office, individuals must meet certain requirements to be eligible for federal HIPAA protections. You must have at least 18 months of creditable coverage with no significant break (at least 63 consecutive days with no coverage, excluding any waiting periods). Through your own coverage or a family member's, your most recent coverage must have been under a group health plan. You cannot be eligible for coverage under any other group health plan, or through Medicaid or Medicare, and you must not have any other health insurance coverage. Your loss of health insurance can't result from nonpayment or fraud. And you must have exhausted any COBRA or similar state-based coverage.

HIPAA for Illinois' Small Employers

• The Illinois Health Insurance Portability and Accountability Act (215 ILCS 97) provides safeguards for small employers (generally 2 to 50 employees) changing group health plans. This law requires insurers to guarantee access to any policy sold in the small employee market statewide. In other words, health insurance providers can't pick and choose which small employers they'll accept; every small employer that applies for coverage sold to other small employers must be accepted.

  Exceptions apply if an employer doesn't meet the definition of "small employer" as defined in the act or if minimum participation requirements have not been met.

HIPAA Enforcement

• In cases when a health insurance company is not in compliance with the federal HIPAA law, the Illinois attorney general's office and state insurance commissioner handle enforcement. However, when an employer's group health plan is suspected of noncompliance, the U.S. Department of Labor is in charge of enforcement. Accordingly, any compliance issues regarding the Illinois HIPAA law are enforced at the state level.